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Biancari F, Mäkikallio T, Loforte A, Kaserer A, Ruggieri VG, Cho SM, Kang JK, Dalén M, Welp H, Jónsson K, Ragnarsson S, Hernández Pérez FJ, Gatti G, Alkhamees K, Fiore A, Lechiancole A, Rosato S, Spadaccio C, Pettinari M, Perrotti A, Sahli SD, L'Acqua C, Arafat AA, Albabtain MA, AlBarak MM, Laimoud M, Djordjevic I, Krasivskyi I, Samalavicius R, Jankuviene A, Alonso-Fernandez-Gatta M, Wilhelm MJ, Juvonen T, Mariscalco G. Inter-institutional analysis of the outcome after postcardiotomy veno-arterial extracorporeal membrane oxygenation. Int J Artif Organs 2024; 47:25-34. [PMID: 38053227 DOI: 10.1177/03913988231214934] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/07/2023]
Abstract
INTRODUCTION Patients requiring postcardiotomy veno-arterial extracorporeal membrane oxygenation (V-A-ECMO) have a high risk of early mortality. In this analysis, we evaluated whether any interinstitutional difference exists in the results of postcardiotomy V-A-ECMO. METHODS Studies on postcardiotomy V-A-ECMO were identified through a systematic review for individual patient data (IPD) meta-analysis. Analysis of interinstitutional results was performed using direct standardization, estimation of observed/expected in-hospital mortality ratio and propensity score matching. RESULTS Systematic review of the literature yielded 31 studies. Data from 10 studies on 1269 patients treated at 25 hospitals were available for the present analysis. In-hospital mortality was 66.7%. The relative risk of in-hospital mortality was significantly higher in six hospitals. Observed versus expected in-hospital mortality ratio showed that four hospitals were outliers with significantly increased mortality rates, and one hospital had significantly lower in-hospital mortality rate. Participating hospitals were classified as underperforming and overperforming hospitals if their observed/expected in-hospital mortality was higher or lower than 1.0, respectively. Among 395 propensity score matched pairs, the overperforming hospitals had significantly lower in-hospital mortality (60.3% vs 71.4%, p = 0.001) than underperforming hospitals. Low annual volume of postcardiotomy V-A-ECMO tended to be predictive of poor outcome only when adjusted for patients' risk profile. CONCLUSIONS In-hospital mortality after postcardiotomy V-A-ECMO differed significantly between participating hospitals. These findings suggest that in many centers there is room for improvement of the results of postcardiotomy V-A-ECMO.
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Affiliation(s)
- Fausto Biancari
- Heart and Lung Center, Helsinki University Hospital, Helsinki, Finland
- Department of Medicine, South-Karelia Central Hospital, University of Helsinki, Helsinki, Finland
| | - Timo Mäkikallio
- Department of Medicine, South-Karelia Central Hospital, University of Helsinki, Helsinki, Finland
| | - Antonio Loforte
- Department of Cardiothoracic, Transplantation and Vascular Surgery, S. Orsola Hospital, University of Bologna, Bologna, and Department of Surgical Science, University of Turin, Turin, Italy
| | - Alexander Kaserer
- Institute of Anesthesiology, University and University Hospital Zurich, Zurich, Switzerland
| | - Vito G Ruggieri
- Division of Cardiothoracic and Vascular Surgery, Robert Debré University Hospital, Reims, France
| | - Sung-Min Cho
- Division of Neurosciences, Critical Care and Cardiac Surgery, Departments of Neurology, Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jin Kook Kang
- Division of Neurosciences, Critical Care and Cardiac Surgery, Departments of Neurology, Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Magnus Dalén
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Henryk Welp
- Department of Cardiothoracic Surgery, Münster University Hospital, Münster, Germany
| | - Kristján Jónsson
- Department of Cardiac Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
| | | | | | - Giuseppe Gatti
- Division of Cardiac Surgery, Cardio-Thoracic and Vascular Department, University Hospital of Trieste, Trieste, Italy
| | | | - Antonio Fiore
- Department of Cardiac Surgery, Hôpitaux Universitaires Henri Mondor, Creteil, France
| | | | - Stefano Rosato
- Center for Global Health, Italian National Institute, Rome, Italy
| | | | - Matteo Pettinari
- Department of Cardiovascular Surgery, Ziekenhuis Oost-Limburg, Genk, Belgium
| | - Andrea Perrotti
- Department of Thoracic and Cardio-Vascular Surgery, University Hospital Jean Minjoz, Besançon, France
| | - Sebastian D Sahli
- Institute of Anesthesiology, University and University Hospital Zurich, Zurich, Switzerland
| | - Camilla L'Acqua
- Anesthesia and Intensive Care Unit, Centro Cardiologico Monzino, Milan, Italy
- Anesthesia and Intensive Care Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Amr A Arafat
- Adult Cardiac Surgery, Prince Sultan Cardiac Center, Riyadh, Saudi Arabia
- Cardiothoracic Surgery Department, Tanta University, Tanta, Egypt
| | - Monirah A Albabtain
- Cardiology Clinical Pharmacy, Prince Sultan Cardiac Center, Riyadh, Saudi Arabia
| | - Mohammed M AlBarak
- Intensive Care Department, Prince Sultan Cardiac Center, Riyadh, Saudi Arabia
| | - Mohamed Laimoud
- Cardiac Surgical Intensive Care Department, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
- Critical Care Medicine Department, Cairo University, Cairo, Egypt
| | - Ilija Djordjevic
- Department of Cardiothoracic Surgery, University Hospital Cologne, Cologne, Germany
| | - Ihor Krasivskyi
- Department of Cardiothoracic Surgery, University Hospital Cologne, Cologne, Germany
| | - Robertas Samalavicius
- II Department of Anesthesia, Vilnius University Hospital Santaros Klinikos, Vilnius, Lithuania
- Clinic of Emergency Medicine, Medical Faculty, Vilnius University, Vilnius, Lithuania
| | - Agne Jankuviene
- II Department of Anesthesia, Vilnius University Hospital Santaros Klinikos, Vilnius, Lithuania
| | - Marta Alonso-Fernandez-Gatta
- Cardiology Department, University Hospital of Salamanca, Instituto de Investigación Biomédica de Salamanca, Salamanca, Spain
- CIBER-CV Instituto de Salud Carlos III, Madrid, Spain
| | - Markus J Wilhelm
- Clinic for Cardiac Surgery, University Heart Center, University and University Hospital Zurich, Zurich, Switzerland
| | - Tatu Juvonen
- Heart and Lung Center, Helsinki University Hospital, Helsinki, Finland
- Research Unit of Surgery, Anesthesia and Intensive Care, University of Oulu, Oulu, Finland
| | - Giovanni Mariscalco
- Department of Intensive Care Medicine and Cardiac Surgery, Glenfield Hospital, University Hospitals of Leicester, Leicester, UK
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Mariani S, Wang IW, van Bussel BCT, Heuts S, Wiedemann D, Saeed D, van der Horst ICC, Pozzi M, Loforte A, Boeken U, Samalavicius R, Bounader K, Hou X, Bunge JJH, Buscher H, Salazar L, Meyns B, Herr D, Matteucci S, Sponga S, Ramanathan K, Russo C, Formica F, Sakiyalak P, Fiore A, Camboni D, Raffa GM, Diaz R, Jung JS, Belohlavek J, Pellegrino V, Bianchi G, Pettinari M, Barbone A, Garcia JP, Shekar K, Whitman G, Lorusso R. The importance of timing in postcardiotomy venoarterial extracorporeal membrane oxygenation: A descriptive multicenter observational study. J Thorac Cardiovasc Surg 2023; 166:1670-1682.e33. [PMID: 37201778 DOI: 10.1016/j.jtcvs.2023.04.042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2023] [Revised: 04/05/2023] [Accepted: 04/22/2023] [Indexed: 05/20/2023]
Abstract
OBJECTIVES Postcardiotomy extracorporeal membrane oxygenation (ECMO) can be initiated intraoperatively or postoperatively based on indications, settings, patient profile, and conditions. The topic of implantation timing only recently gained attention from the clinical community. We compare patient characteristics as well as in-hospital and long-term survival between intraoperative and postoperative ECMO. METHODS The retrospective, multicenter, observational Postcardiotomy Extracorporeal Life Support (PELS-1) study includes adults who required ECMO due to postcardiotomy shock between 2000 and 2020. We compared patients who received ECMO in the operating theater (intraoperative) with those in the intensive care unit (postoperative) on in-hospital and postdischarge outcomes. RESULTS We studied 2003 patients (women: 41.1%; median age: 65 years; interquartile range [IQR], 55.0-72.0). Intraoperative ECMO patients (n = 1287) compared with postoperative ECMO patients (n = 716) had worse preoperative risk profiles. Cardiogenic shock (45.3%), right ventricular failure (15.9%), and cardiac arrest (14.3%) were the main indications for postoperative ECMO initiation, with cannulation occurring after (median) 1 day (IQR, 1-3 days). Compared with intraoperative application, patients who received postoperative ECMO showed more complications, cardiac reoperations (intraoperative: 19.7%; postoperative: 24.8%, P = .011), percutaneous coronary interventions (intraoperative: 1.8%; postoperative: 3.6%, P = .026), and had greater in-hospital mortality (intraoperative: 57.5%; postoperative: 64.5%, P = .002). Among hospital survivors, ECMO duration was shorter after intraoperative ECMO (median, 104; IQR, 67.8-164.2 hours) compared with postoperative ECMO (median, 139.7; IQR, 95.8-192 hours, P < .001), whereas postdischarge long-term survival was similar between the 2 groups (P = .86). CONCLUSIONS Intraoperative and postoperative ECMO implantations are associated with different patient characteristics and outcomes, with greater complications and in-hospital mortality after postoperative ECMO. Strategies to identify the optimal location and timing of postcardiotomy ECMO in relation to specific patient characteristics are warranted to optimize in-hospital outcomes.
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Affiliation(s)
- Silvia Mariani
- Cardio-Thoracic Surgery Department, Maastricht University Medical Center, and Cardiovascular Research Institute Maastricht (CAIRM), Maastricht, The Netherlands.
| | - I-Wen Wang
- Division of Cardiac Surgery, Memorial Healthcare System, Hollywood, Calif
| | - Bas C T van Bussel
- Department of Intensive Care Medicine, Maastricht University Medical Center, and Cardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherlands
| | - Samuel Heuts
- Cardio-Thoracic Surgery Department, Maastricht University Medical Center, and Cardiovascular Research Institute Maastricht (CAIRM), Maastricht, The Netherlands
| | - Dominik Wiedemann
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Diyar Saeed
- Department of Cardiac Surgery, Leipzig Heart Center, Leipzig, Germany
| | - Iwan C C van der Horst
- Department of Intensive Care Medicine, Maastricht University Medical Center, and Cardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherlands
| | - Matteo Pozzi
- Department of Cardiac Surgery, Louis Pradel Cardiologic Hospital, Lyon, France
| | - Antonio Loforte
- Division of Cardiac Surgery, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Udo Boeken
- Department of Cardiac Surgery, Medical Faculty, Heinrich Heine University, Duesseldorf, Germany
| | - Robertas Samalavicius
- II Department of Anesthesiology, Centre of Anesthesia, Intensive Care and Pain management, Vilnius University Hospital Santariskiu Klinikos, Vilnius, Lithuania
| | - Karl Bounader
- Division of Cardiothoracic and Vascular Surgery, Pontchaillou University Hospital, Rennes, France
| | - Xiaotong Hou
- Center for Cardiac Intensive Care, Beijing Institute of Heart, Lung, and Blood Vessels Diseases, Beijing Anzhen Hospital, Beijing, China
| | - Jeroen J H Bunge
- Department of Intensive Care Adults, Erasmus MC, Rotterdam, The Netherlands
| | - Hergen Buscher
- Department of Intensive Care Medicine, Center of Applied Medical Research, St Vincent's Hospital, Darlinghurst, Australia
| | - Leonardo Salazar
- Department of Cardiology, Fundación Cardiovascular de Colombia, Bucaramanga, Colombia
| | - Bart Meyns
- Department of Cardiac Surgery, University Hospitals Leuven, and Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium
| | - Daniel Herr
- Departments of Medicine and Surgery, University of Maryland, Baltimore, Md
| | - Sacha Matteucci
- SOD Cardiochirurgia Ospedali Riuniti 'Umberto I-Lancisi-Salesi' Università Politecnica delle Marche, Ancona, Italy
| | - Sandro Sponga
- Division of Cardiac Surgery, Cardiothoracic Department, University Hospital of Udine, Udine, Italy
| | - Kollengode Ramanathan
- Cardiothoracic Intensive Care Unit, National University Heart Centre, National University Hospital, Singapore, Singapore
| | - Claudio Russo
- Cardiac Surgery Unit, Cardiac Thoracic and Vascular Department, Niguarda Hospital, Milan, Italy
| | - Francesco Formica
- Department of Medicine and Surgery, Cardiac Surgery Clinic, San Gerardo Hospital, University of Milano-Bicocca, Monza, Italy, and Department of Medicine and Surgery, University of Parma, Cardiac Surgery Unit, University Hospital of Parma, Parma, Italy
| | - Pranya Sakiyalak
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Faculty of Medicine, Siriraj Hospital, Bangkok, Thailand
| | - Antonio Fiore
- Department of Cardio-Thoracic Surgery, University Hospital Henri-Mondor, Créteil, Paris, France
| | - Daniele Camboni
- Department of Cardiothoracic Surgery, University Medical Center Regensburg, Regensburg, Germany
| | - Giuseppe Maria Raffa
- Department for the Treatment and Study of Cardiothoracic Diseases and Cardiothoracic Transplantation, Istituto Mediterraneo per i Trapianti e Terapie ad Alta Specializzazione, Palermo, Italy
| | - Rodrigo Diaz
- ECMO Unit, Departamento de Anestesia, Clínica Las Condes, Santiago, Chile
| | - Jae-Seung Jung
- Department of Thoracic and Cardiovascular Surgery, Korea University Anam Hospital, Seoul, South Korea
| | - Jan Belohlavek
- 2nd Department of Internal Medicine, Cardiovascular Medicine General Teaching Hospital and 1st Faculty of Medicine, Charles University in Prague, Prague, Czech Republic
| | - Vin Pellegrino
- Intensive Care Unit, The Alfred Hospital, Melbourne, Australia
| | - Giacomo Bianchi
- Ospedale del Cuore Fondazione Toscana "G. Monasterio", Massa, Italy
| | - Matteo Pettinari
- Department of Cardiovascular Surgery, Ziekenhuis Oost-Limburg, Genk, Belgium
| | | | - José P Garcia
- IU Health Advanced Heart & Lung Care, Indiana University Methodist Hospital, Indianapolis, Ind
| | - Kiran Shekar
- Adult Intensive Care Services, The Prince Charles Hospital, Brisbane, Australia
| | - Glenn Whitman
- Cardiac Intensive Care Unit, Johns Hopkins Hospital, Baltimore, Md
| | - Roberto Lorusso
- Cardio-Thoracic Surgery Department, Maastricht University Medical Center, and Cardiovascular Research Institute Maastricht (CAIRM), Maastricht, The Netherlands
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3
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Mariani S, Heuts S, van Bussel BCT, Di Mauro M, Wiedemann D, Saeed D, Pozzi M, Loforte A, Boeken U, Samalavicius R, Bounader K, Hou X, Bunge JJH, Buscher H, Salazar L, Meyns B, Herr D, Matteucci MLS, Sponga S, MacLaren G, Russo C, Formica F, Sakiyalak P, Fiore A, Camboni D, Raffa GM, Diaz R, Wang I, Jung J, Belohlavek J, Pellegrino V, Bianchi G, Pettinari M, Barbone A, Garcia JP, Shekar K, Whitman GJR, Lorusso R. Patient and Management Variables Associated With Survival After Postcardiotomy Extracorporeal Membrane Oxygenation in Adults: The PELS-1 Multicenter Cohort Study. J Am Heart Assoc 2023; 12:e029609. [PMID: 37421269 PMCID: PMC10382118 DOI: 10.1161/jaha.123.029609] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Accepted: 05/25/2023] [Indexed: 07/10/2023]
Abstract
Background Extracorporeal membrane oxygenation (ECMO) has been increasingly used for postcardiotomy cardiogenic shock, but without a concomitant reduction in observed in-hospital mortality. Long-term outcomes are unknown. This study describes patients' characteristics, in-hospital outcome, and 10-year survival after postcardiotomy ECMO. Variables associated with in-hospital and postdischarge mortality are investigated and reported. Methods and Results The retrospective international multicenter observational PELS-1 (Postcardiotomy Extracorporeal Life Support) study includes data on adults requiring ECMO for postcardiotomy cardiogenic shock between 2000 and 2020 from 34 centers. Variables associated with mortality were estimated preoperatively, intraoperatively, during ECMO, and after the occurrence of any complications, and then analyzed at different time points during a patient's clinical course, through mixed Cox proportional hazards models containing fixed and random effects. Follow-up was established by institutional chart review or contacting patients. This analysis included 2058 patients (59% were men; median [interquartile range] age, 65.0 [55.0-72.0] years). In-hospital mortality was 60.5%. Independent variables associated with in-hospital mortality were age (hazard ratio [HR], 1.02 [95% CI, 1.01-1.02]) and preoperative cardiac arrest (HR, 1.41 [95% CI, 1.15-1.73]). In the subgroup of hospital survivors, the overall 1-, 2-, 5-, and 10-year survival rates were 89.5% (95% CI, 87.0%-92.0%), 85.4% (95% CI, 82.5%-88.3%), 76.4% (95% CI, 72.5%-80.5%), and 65.9% (95% CI, 60.3%-72.0%), respectively. Variables associated with postdischarge mortality included older age, atrial fibrillation, emergency surgery, type of surgery, postoperative acute kidney injury, and postoperative septic shock. Conclusions In adults, in-hospital mortality after postcardiotomy ECMO remains high; however, two-thirds of those who are discharged from hospital survive up to 10 years. Patient selection, intraoperative decisions, and ECMO management remain key variables associated with survival in this cohort. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT03857217.
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Affiliation(s)
- Silvia Mariani
- Cardio‐Thoracic Surgery Department and Cardiovascular Research Institute MaastrichtMaastrichtthe Netherlands
| | - Samuel Heuts
- Cardio‐Thoracic Surgery Department and Cardiovascular Research Institute MaastrichtMaastrichtthe Netherlands
| | - Bas C. T. van Bussel
- Department of Intensive Care Medicine and Cardiovascular Research Institute MaastrichtMaastrichtthe Netherlands
| | - Michele Di Mauro
- Cardio‐Thoracic Surgery Department and Cardiovascular Research Institute MaastrichtMaastrichtthe Netherlands
| | - Dominik Wiedemann
- Department of Cardiac SurgeryMedical University of ViennaViennaAustria
| | - Diyar Saeed
- Department of Cardiac SurgeryLeipzig Heart CenterLeipzigGermany
| | - Matteo Pozzi
- Department of Cardiac Surgery, Louis Pradel Cardiologic HospitalLyonFrance
| | - Antonio Loforte
- Division of Cardiac SurgeryIstituto di Ricovero e Cura a Carattere Scientifico Azienda Ospedaliero–Universitaria di BolognaBolognaItaly
- Department of Surgical SciencesUniversity of TurinTurinItaly
| | - Udo Boeken
- Department of Cardiac Surgery, Medical FacultyHeinrich Heine UniversityDuesseldorfGermany
| | - Robertas Samalavicius
- II Department of Anesthesiology, Centre of Anesthesia, Intensive Care and Pain ManagementVilnius University Hospital Santariskiu KlinikosVilniusLithuania
| | - Karl Bounader
- Division of Cardiothoracic and Vascular SurgeryPontchaillou University HospitalRennesFrance
| | - Xiaotong Hou
- Center for Cardiac Intensive CareBeijing Institute of Heart, Lung, and Blood Vessels Diseases, Beijing Anzhen Hospital, Capital Medical UniversityBeijingChina
| | - Jeroen J. H. Bunge
- Department of Intensive Care AdultsErasmus Medical CenterRotterdamthe Netherlands
| | - Hergen Buscher
- Department of Intensive Care Medicine, Center of Applied Medical ResearchSt Vincent’s HospitalDarlinghursNew South WalesAustralia
- University of New South WalesSydneyAustralia
| | - Leonardo Salazar
- Department of Cardiology, Fundación Cardiovascular de ColombiaBucaramangaColombia
| | - Bart Meyns
- Department of Cardiac SurgeryUniversity Hospitals Leuven and Department of Cardiovascular Sciences, University of LeuvenLeuvenBelgium
| | - Daniel Herr
- Departments of Medicine and SurgeryUniversity of MarylandBaltimoreMD
| | - Marco L. Sacha Matteucci
- Struttura Organizzativa Dipartimentale di CardiochirurgiaOspedali Riuniti ‘Umberto I–Lancisi‐Salesi’ Università Politecnica delle MarcheAnconaItaly
| | - Sandro Sponga
- Division of Cardiac Surgery, Cardiothoracic DepartmentUniversity Hospital of UdineUdineItaly
| | - Graeme MacLaren
- Cardiothoracic Intensive Care UnitNational University Heart Centre, National University HospitalSingaporeSingapore
| | - Claudio Russo
- Cardiac Surgery Unit, Cardiac Thoracic and Vascular Department, Niguarda HospitalMilanItaly
| | - Francesco Formica
- Department of Medicine and Surgery, Cardiac Surgery Clinic, San Gerardo HospitalUniversity of Milano‐BicoccaMonzaItaly
- Department of Medicine and SurgeryUniversity of Parma, Cardiac Surgery Unit, University Hospital of ParmaParmaItaly
| | - Pranya Sakiyalak
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Faculty of Medicine Siriraj HospitalMahidol UniversityBangkokThailand
| | - Antonio Fiore
- Department of Cardio‐Thoracic SurgeryUniversity Hospital Henri‐Mondor, CréteilParisFrance
| | - Daniele Camboni
- Department of Cardiothoracic SurgeryUniversity Medical Center RegensburgRegensburgGermany
| | - Giuseppe Maria Raffa
- Department for the Treatment and Study of Cardiothoracic Diseases and Cardiothoracic TransplantationIstituti di Ricovero e Cura a Carattere Scientifico ‐ Istituto Mediterraneo per i Trapianti e Terapie ad Alta Specializzazione)PalermoItaly
| | - Rodrigo Diaz
- Extracorporeal Membrane Oxygenation Unit, Departamento de AnestesiaClínica Las Condes, Las CondesSantiagoChile
| | - I‐wen Wang
- Division of Cardiac Surgery, Memorial Healthcare SystemHollywoodFL
| | - Jae‐Seung Jung
- Department of Thoracic and Cardiovascular SurgeryKorea University Anam HospitalSeoulSouth Korea
| | - Jan Belohlavek
- 2nd Department of Internal Medicine, Cardiovascular Medicine General Teaching Hospital and 1st Faculty of MedicineCharles University in PraguePragueCzech Republic
| | - Vin Pellegrino
- Intensive Care Unit, The Alfred HospitalMelbourneVictoriaAustralia
| | - Giacomo Bianchi
- Ospedale del Cuore Fondazione Toscana "G. Monasterio"MassaItaly
| | - Matteo Pettinari
- Department of Cardiovascular Surgery, Ziekenhuis Oost‐LimburgGenkBelgium
| | - Alessandro Barbone
- Cardiac Surgery UnitIstituto di Ricovero e Cura a Carattere Scientifico Humanitas Research HospitalRozzanoMilanItaly
| | - José P. Garcia
- Indiana University Health Advanced Heart and Lung Care, Indiana University Methodist HospitalIndianapolisIN
| | - Kiran Shekar
- Adult Intensive Care Services, The Prince Charles HospitalBrisbaneAustralia
| | | | - Roberto Lorusso
- Cardio‐Thoracic Surgery Department and Cardiovascular Research Institute MaastrichtMaastrichtthe Netherlands
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4
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Biancari F, Kaserer A, Perrotti A, Ruggieri VG, Cho SM, Kang JK, Dalén M, Welp H, Jónsson K, Ragnarsson S, Hernández Pérez FJ, Gatti G, Alkhamees K, Loforte A, Lechiancole A, Rosato S, Spadaccio C, Pettinari M, Mariscalco G, Mäkikallio T, Sahli SD, L'Acqua C, Arafat AA, Albabtain MA, AlBarak MM, Laimoud M, Djordjevic I, Krasivskyi I, Samalavicius R, Puodziukaite L, Alonso-Fernandez-Gatta M, Spahn DR, Fiore A. Hyperlactatemia and poor outcome After postcardiotomy veno-arterial extracorporeal membrane oxygenation: An individual patient data meta-Analysis. Perfusion 2023:2676591231170978. [PMID: 37066850 DOI: 10.1177/02676591231170978] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/18/2023]
Abstract
INTRODUCTION Postcardiotomy veno-arterial extracorporeal membrane oxygenation (V-A-ECMO) is associated with significant mortality. Identification of patients at very high risk for death is elusive and the decision to initiate V-A-ECMO is based on clinical judgment. The prognostic impact of pre-V-A-ECMO arterial lactate level in these critically ill patients has been herein evaluated. METHODS A systematic review was conducted to identify studies on postcardiotomy VA-ECMO for the present individual patient data meta-analysis. RESULTS Overall, 1269 patients selected from 10 studies were included in this analysis. Arterial lactate level at V-A-ECMO initiation was increased in patients who died during the index hospitalization compared to those who survived (9.3 vs 6.6 mmol/L, p < 0.0001). Accordingly, in hospital mortality increased along quintiles of pre-V-A-ECMO arterial lactate level (quintiles: 1, 54.9%; 2, 54.9%; 3, 67.3%; 4, 74.2%; 5, 82.2%, p < 0.0001). The best cut-off for arterial lactate was 6.8 mmol/L (in-hospital mortality, 76.7% vs. 55.7%, p < 0.0001). Multivariable multilevel mixed-effect logistic regression model including arterial lactate level significantly increased the area under the receiver operating characteristics curve (0.731, 95% CI 0.702-0.760 vs 0.679, 95% CI 0.648-0.711, DeLong test p < 0.0001). Classification and regression tree analysis showed the in-hospital mortality was 85.2% in patients aged more than 70 years with pre-V-A-ECMO arterial lactate level ≥6.8 mmol/L. CONCLUSIONS Among patients requiring postcardiotomy V-A-ECMO, hyperlactatemia was associated with a marked increase of in-hospital mortality. Arterial lactate may be useful in guiding the decision-making process and the timing of initiation of postcardiotomy V-A-ECMO.
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Affiliation(s)
- Fausto Biancari
- Heart and Lung Center, Helsinki University Hospital, Helsinki, Finland
- Department of Medicine, South-Karelia Central Hospital, University of Helsinki, Lappeenranta, Finland
| | - Alexander Kaserer
- Institute of Anesthesiology, University and University Hospital Zurich, Zurich, Switzerland
| | - Andrea Perrotti
- Department of Thoracic and Cardio-Vascular Surgery, University Hospital Jean Minjoz, Besançon, France
| | - Vito G Ruggieri
- Division of Cardiothoracic and Vascular Surgery, Robert Debré University Hospital, Reims, France
| | - Sung-Min Cho
- Departments of Neurology, Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, USA
| | - Jin Kook Kang
- Departments of Neurology, Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, USA
| | - Magnus Dalén
- Department of Molecular Medicine and Surgery, and Cardiac Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Henryk Welp
- Department of Cardiothoracic Surgery, Münster University Hospital, Münster, Germany
| | - Kristján Jónsson
- Department of Cardiac Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
| | | | | | - Giuseppe Gatti
- Cardio-Thoracic and Vascular Department, University Hospital of Trieste, Trieste, Italy
| | | | - Antonio Loforte
- Department of Cardiothoracic, Transplantation and Vascular Surgery, S. Orsola Hospital, Bologna, Italy
| | | | - Stefano Rosato
- Center for Global Health, Italian National Institute, Rome, Italy
| | | | - Matteo Pettinari
- Department of Cardiovascular Surgery, Ziekenhuis Oost-Limburg, 3600 Genk, Belgium
| | - Giovanni Mariscalco
- Department of Intensive Care Medicine and Cardiac Surgery, Glenfield Hospital, Leicester, UK
| | - Timo Mäkikallio
- Department of Medicine, South-Karelia Central Hospital, University of Helsinki, Lappeenranta, Finland
| | - Sebastian D Sahli
- Institute of Anesthesiology, University and University Hospital Zurich, Zurich, Switzerland
| | - Camilla L'Acqua
- Anesthesia and Intensive Care Unit, Centro Cardiologico Monzino, Italy
- Anesthesia and Intensive Care Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Italy
| | - Amr A Arafat
- Adult Cardiac Surgery, Prince Sultan Cardiac Center, Riyadh, Saudi Arabia
- Cardiothoracic Surgery Department, Tanta University, Tanta, Egypt
| | - Monirah A Albabtain
- Cardiology Clinical Pharmacy, Prince Sultan Cardiac Center, Riyadh, Saudi Arabia
| | - Mohammed M AlBarak
- Intensive Care Department, Prince Sultan Cardiac Center, Riyadh, Saudi Arabia
| | - Mohamed Laimoud
- Cardiac Surgical Intensive Care Department, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
- Critical Care Medicine Department, Cairo University, Cairo, Egypt
| | - Ilija Djordjevic
- Department of Cardiothoracic Surgery, University Hospital Cologne, Cologne, Germany
| | - Ihor Krasivskyi
- Department of Cardiothoracic Surgery, University Hospital Cologne, Cologne, Germany
| | - Robertas Samalavicius
- 2nd Department of Anesthesia, Vilnius University Hospital Santaros Klinikos, Vilnius, Lithuania
- Clinic of Emergency Medicine, Medical Faculty, Vilnius University, Vilnius, Lithuania
| | - Lina Puodziukaite
- 2nd Department of Anesthesia, Vilnius University Hospital Santaros Klinikos, Vilnius, Lithuania
| | - Marta Alonso-Fernandez-Gatta
- Cardiology Department, University Hospital of Salamanca, Instituto de Investigación Biomédica de Salamanca, Salamanca, Spain
- CIBER-CV Instituto de Salud Carlos III, Madrid, Spain
| | - Donat R Spahn
- Institute of Anesthesiology, University and University Hospital Zurich, Zurich, Switzerland
| | - Antonio Fiore
- Department of Cardiac Surgery, Hôpitaux Universitaires Henri Mondor, Creteil, France
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5
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Cusanno A, Aissaoui N, Minville V, Porterie J, Biendel C, Volle K, Crognier L, Conil JM, Delmas C. Predictors of weaning failure in case of VA ECMO implantation. Sci Rep 2022; 12:13842. [PMID: 35974037 PMCID: PMC9381562 DOI: 10.1038/s41598-022-18105-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Accepted: 08/05/2022] [Indexed: 11/09/2022] Open
Abstract
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.
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Affiliation(s)
- Axelle Cusanno
- Department of Anesthesia, Intensive Care and Perioperative Care Medicine, Rangueil University Hospital, Toulouse, France
| | - Nadia Aissaoui
- Medical Intensive Care Unit, Hôpital Cochin, AP-HP, Paris, France
| | - Vincent Minville
- Department of Anesthesia, Intensive Care and Perioperative Care Medicine, Rangueil University Hospital, Toulouse, France
| | - Jean Porterie
- Department of Cardiovascular Surgery, Rangueil University Hospital, Toulouse, France
| | - Caroline Biendel
- Intensive Cardiac Care Unit, Department of Cardiology, Rangueil University Hospital, Toulouse, France
| | - Kim Volle
- Department of Anesthesia, Intensive Care and Perioperative Care Medicine, Rangueil University Hospital, Toulouse, France.,Intensive Cardiac Care Unit, Department of Cardiology, Rangueil University Hospital, Toulouse, France
| | - Laure Crognier
- Department of Anesthesia, Intensive Care and Perioperative Care Medicine, Rangueil University Hospital, Toulouse, France
| | - Jean-Marie Conil
- Department of Anesthesia, Intensive Care and Perioperative Care Medicine, Rangueil University Hospital, Toulouse, France
| | - Clément Delmas
- Intensive Cardiac Care Unit, Department of Cardiology, Toulouse University Hospital, 1, avenue Jean Poulhès, TSA 50032, 31059, Toulouse Cedex 9, France.
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6
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Björnsdóttir B, Biancari F, Dalén M, Dell'Aquila AM, Jónsson K, Fiore A, Mariscalco G, El-Dean Z, Gatti G, Zipfel S, Perrotti A, Bounader K, Alkhamees K, Loforte A, Lechiancole A, Pol M, Spadaccio C, Pettinari M, De Keyzer D, Welp H, Speziale G, Lichtenberg A, Ruggieri VG, Yusuf H, Ragnarsson S. Postcardiotomy Venoarterial Extracorporeal Membrane Oxygenation With and Without Intra-Aortic Balloon Pump. J Cardiothorac Vasc Anesth 2022; 36:2876-2883. [PMID: 35304046 DOI: 10.1053/j.jvca.2022.02.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2021] [Revised: 02/04/2022] [Accepted: 02/05/2022] [Indexed: 12/14/2022]
Abstract
OBJECTIVES To compare the outcomes of patients with postcardiotomy shock treated with venoarterial extracorporeal membrane oxygenation (VA-ECMO) only compared with VA-ECMO and intra-aortic balloon pump (IABP). DESIGN A retrospective multicenter registry study. SETTING At 19 cardiac surgery units. PARTICIPANTS A total of 615 adult patients who required VA-ECMO from 2010 to 2018. The patients were divided into 2 groups depending on whether they received VA-ECMO only (ECMO only group) or VA-ECMO plus IABP (ECMO-IABP group). MEASUREMENTS AND MAIN RESULTS The overall series mean age was 63 ± 13 years, and 33% were female. The ECMO-only group included 499 patients, and 116 patients were in the ECMO-IABP group. Urgent and/or emergent procedures were more common in the ECMO-only group. Central cannulation was performed in 47% (n = 54) in the ECMO-IABP group compared to 27% (n = 132) in the ECMO-only group. In the ECMO-IABP group, 58% (n = 67) were successfully weaned from ECMO, compared to 46% (n = 231) in the ECMO-only group (p = 0.026). However, in-hospital mortality was 63% in the ECMO-IABP group compared to 65% in the ECMO-only group (p = 0.66). Among 114 propensity score-matched pairs, ECMO-IABP group had comparable weaning rates (57% v 53%, p = 0.51) and in-hospital mortality (64% v 58%, p = 0.78). CONCLUSIONS This multicenter study showed that adjunctive IABP did not translate into better outcomes in patients treated with VA-ECMO for postcardiotomy shock.
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Affiliation(s)
- Björk Björnsdóttir
- Department of Cardiothoracic Surgery, Skane University Hospital and Lund University, Lund, Sweden
| | - Fausto Biancari
- Clinica Montevergine, GVM Care & Research, Mercogliano, Italy; Heart and Lung Center, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Magnus Dalén
- Department of Molecular Medicine and Surgery, Department of Cardiac Surgery, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Angelo M Dell'Aquila
- Department of Cardiothoracic Surgery, Münster University Hospital, Münster, Germany
| | - Kristján Jónsson
- Department of Cardiac Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Antonio Fiore
- Department of Cardiothoracic Surgery, Henri Mondor University Hospital, AP-HP, Paris-Est University, Créteil, France
| | - Giovanni Mariscalco
- Department of Cardiac Surgery, Glenfield Hospital, University Hospitals of Leicester NHS Trust, Leicester, United Kingdom
| | - Zein El-Dean
- Department of Cardiac Surgery, Glenfield Hospital, University Hospitals of Leicester NHS Trust, Leicester, United Kingdom
| | - Giuseppe Gatti
- Division of Cardiac Surgery, Ospedali Riuniti, Trieste, Italy
| | | | - Andrea Perrotti
- Department of Thoracic and Cardio-Vascular Surgery, University Hospital Jean Minjoz, Besançon, France
| | - Karl Bounader
- Division of Cardiothoracic and Vascular Surgery, Pontchaillou University Hospital, Rennes, France
| | | | - Antonio Loforte
- Department of Cardiothoracic, Transplantation and Vascular Surgery, S. Orsola Hospital, University of Bologna, Bologna, Italy
| | | | - Marek Pol
- Institute of Clinical and Experimental Medicine, Prague, Czech Republic
| | - Cristiano Spadaccio
- Department of Cardiothoracic Surgery, Golden Jubilee National Hospital, Glasgow, United Kingdom; Department of Cardiac Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Matteo Pettinari
- Department of Cardiovascular Surgery, Ziekenhuis Oost-Limburg, Genk, Belgium
| | - Dieter De Keyzer
- Department of Cardiovascular Surgery, Ziekenhuis Oost-Limburg, Genk, Belgium
| | - Henryk Welp
- Department of Cardiothoracic Surgery, Münster University Hospital, Münster, Germany
| | - Giuseppe Speziale
- Division of Cardiac Surgery, Anthea Hospital, GVM Care & Research, Bari, Italy
| | - Artur Lichtenberg
- Department of Cardiovascular Surgery, Universitätsklinikum Düsseldorf, Düsseldorf, Germany
| | - Vito G Ruggieri
- Division of Cardiothoracic and Vascular Surgery, Robert Debré University Hospital, Reims, France
| | - Hakeem Yusuf
- Department of Cardiac Anesthesia and Intensive Care, Glenfield Hospital, University Hospitals of Leicester NHS Trust, Leicester, United Kingdom
| | - Sigurdur Ragnarsson
- Department of Cardiothoracic Surgery, Skane University Hospital and Lund University, Lund, Sweden.
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7
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Karnib M, Haraf R, Tashtish N, Zanath E, Elshazly T, Garcia RA, Billings S, Fetros M, Bradigan A, Zacharias M, Abu-Omar Y, Elgudin Y, Pelletier M, Al-Kindi S, Lytle F, ElAmm C. MELD score is predictive of 90-day mortality after veno-arterial extracorporeal membrane oxygenation support. Int J Artif Organs 2021; 45:404-411. [PMID: 34702105 DOI: 10.1177/03913988211054865] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND The Model for End-Stage Liver Disease (MELD) score was originally described as a marker of survival in chronic liver disease. More recently, MELD and its derivatives, MELD excluding INR (MELD-XI) and MELD with sodium (MELD-Na), have been applied more broadly as outcome predictors in heart transplant, left ventricular assist device placement, heart failure, and cardiogenic shock, with additional promising data to support the use of these scores for prediction of survival in those undergoing veno-arterial extracorporeal membrane oxygenation (VA ECMO). METHODS This study assessed the prognostic impact of MELD in patients with cardiogenic shock undergoing VA ECMO via a single-center retrospective review from January 2014 to March 2020. MELD, MELD-XI, and MELD-Na scores were calculated using laboratory values collected within 48 h of VA ECMO initiation. Multivariate Cox regression analyses determined the association between MELD scores and the primary outcome of 90-day mortality. Receiver operating characteristics (ROC) were used to estimate the discriminatory power for MELD in comparison with previously validated SAVE score. RESULTS Of the 194 patients, median MELD was 20.1 (13.7-26.2), and 90-day mortality was 62.1%. There was a significant association between MELD score and mortality up to 90 days (hazard ratio (HR) = 1.945, 95% confidence interval (95% CI) = 1.244-3.041, p = 0.004) after adjustment for age, indication for VA ECMO, and sex. The prognostic significance of MELD score for 90-day mortality revealed an AUC of 0.645 (95% CI = 0.565-0.725, p < 0.001). MELD-Na score and MELD-XI score were not associated with mortality. CONCLUSION MELD score accurately predicts long-term mortality and may be utilized as a valuable decision-making tool in patients undergoing VA ECMO.
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Affiliation(s)
- Mohamad Karnib
- Division of Cardiovascular Disease, Harrington Heart and Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Rebecca Haraf
- Department of Medicine, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Nour Tashtish
- Division of Cardiovascular Disease, Harrington Heart and Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Erica Zanath
- Department of Anesthesia, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Tarek Elshazly
- Department of Anesthesia, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Raul Angel Garcia
- Department of Cardiovascular Disease, Saint Luke's Mid America Heart Institute, University of Missouri, Kansas City, MO, USA
| | - Scott Billings
- Enterprise Data Services Department, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Michael Fetros
- Enterprise Data Services Department, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Allison Bradigan
- Department of Medicine, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Michael Zacharias
- Division of Cardiovascular Disease, Harrington Heart and Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Yasir Abu-Omar
- Division of Cardiovascular Surgery, Harrington Heart and Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Yakov Elgudin
- Division of Cardiovascular Surgery, Harrington Heart and Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Marc Pelletier
- Division of Cardiovascular Surgery, Harrington Heart and Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Sadeer Al-Kindi
- Division of Cardiovascular Disease, Harrington Heart and Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Francis Lytle
- Department of Anesthesia, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Chantal ElAmm
- Division of Cardiovascular Disease, Harrington Heart and Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
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8
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Mørk SR, Frederiksen CA, Nielsen RR, Lichscheidt E, Christensen S, Greisen JR, Tang M, Vase H, Løgstrup BB, Mellemkjær S, Wiggers HS, Mølgaard H, Poulsen SH, Terkelsen CJ, Eiskjær H. A systematic approach to weaning from extracorporeal membrane oxygenation in patients with refractory cardiac failure. Acta Anaesthesiol Scand 2021; 65:936-943. [PMID: 33728635 DOI: 10.1111/aas.13814] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/22/2021] [Indexed: 01/10/2023]
Abstract
BACKGROUND Veno-arterial extracorporeal membrane oxygenation (V-A ECMO) is commonly used to provide haemodynamic support for patients with severe cardiac failure. However, timing ECMO weaning remains challenging. We aimed to examine if an integrative weaning approach based on predefined haemodynamic, respiratory and echocardiographic criteria is associated with successful weaning. METHODS All patients weaned from ECMO between April 2017 and April 2019 at Aarhus University Hospital, Denmark, were consecutively enrolled. Predefined haemodynamic, respiratory and echocardiographic criteria were assessed before and during ECMO flow reduction. A weaning attempt was commenced in haemodynamic stable patients and patients remaining stable at minimal flow were weaned from ECMO. Comparisons were made between patients who met the criteria for weaning at first attempt and patients who did not meet these criteria. Patients completing a full weaning attempt with no further need for mechanical support within 24 h were defined as successfully weaned. RESULTS A total of 38 patients were included in the study, of whom 26 (68%) patients met the criteria for weaning. Among these patients, 25 (96%) could be successfully weaned. Successfully weaned patients were younger and had less need for inotropic support and ECMO duration was shorter. Fulfilling the weaning criteria was associated with successful weaning and both favourable 30-d survival and survival to discharge. CONCLUSION An integrative weaning approach based on haemodynamic, respiratory and echocardiographic criteria may strengthen the clinical decision process in predicting successful weaning in patients receiving ECMO for refractory cardiac failure.
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Affiliation(s)
| | | | - Roni R. Nielsen
- Department of Cardiology Aarhus University Hospital Aarhus Denmark
| | - Emil Lichscheidt
- Department of Cardiology Aarhus University Hospital Aarhus Denmark
| | - Steffen Christensen
- Department of Anaesthesiology and Intensive Care Aarhus University Hospital Aarhus Denmark
| | - Jacob R. Greisen
- Department of Anaesthesiology and Intensive Care Aarhus University Hospital Aarhus Denmark
| | - Mariann Tang
- Deparmtent of Cardiothoracic and Vascular Surgery Aarhus University Hospital Aarhus Denmark
| | - Henrik Vase
- Department of Cardiology Aarhus University Hospital Aarhus Denmark
| | | | - Søren Mellemkjær
- Department of Cardiology Aarhus University Hospital Aarhus Denmark
| | | | - Henning Mølgaard
- Department of Cardiology Aarhus University Hospital Aarhus Denmark
| | - Steen H. Poulsen
- Department of Cardiology Aarhus University Hospital Aarhus Denmark
| | | | - Hans Eiskjær
- Department of Cardiology Aarhus University Hospital Aarhus Denmark
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9
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Ellouze O, Soudry Faure A, Radhouani M, Abou‐Arab O, Besnier E, Moussa M, Cransac A, Ksiazek E, Fischer M, Mertes PM, Bouhemad B, Guinot PG. Levosimendan in venoarterial ECMO weaning. Rational and design of a randomized double blind multicentre trial. ESC Heart Fail 2021; 8:3339-3347. [PMID: 34145993 PMCID: PMC8318420 DOI: 10.1002/ehf2.13427] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Revised: 04/25/2021] [Accepted: 05/02/2021] [Indexed: 12/15/2022] Open
Abstract
AIMS Venoarterial extracorporeal membrane oxygenation (VA-ECMO) is increasingly being used in circulatory failure. The main indications are cardiogenic shock, post-cardiotomy cardiac failure, and refractory cardiac arrest. However, VA-ECMO weaning is particularly challenging, and weaning failure is reported to be as high as 50%, with increased related mortality. Levosimendan is a novel long acting effect inodilator used in cardiogenic shock and terminal heart failure decompensation. Levosimendan use in VA-ECMO patients seems to reduce weaning failure regardless of the initial aetiology and to reduce mortality when administrated early after VA-ECMO initiation. However, studies are limited to retrospective analyses and reported case series. The aim of the WEANILEVO trial is to evaluate whether administration of levosimendan before VA-ECMO weaning is associated with a reduced rates of weaning failure and recourse to other temporary circulatory support. METHODS AND RESULTS WEANILEVO is a randomized, prospective, multicentre, double-blind, parallel-group, controlled trial. One hundred eighty patients will be enrolled if they had acute circulatory heart failure treated with VA-ECMO and for whom weaning is expected within 48 h. The study drugs are either levosimendan (0.2 μg/kg/min for 24 h) or a placebo. The primary endpoint of the trial is the absence of VA-ECMO weaning, recourse to another VA-ECMO, or other temporary circulatory assistance or death within 7 days of VA-ECMO weaning. CONCLUSIONS Levosimendan use in VA-ECMO appears to be beneficial for reducing weaning failure and mortality. The results of WEANILEVO should significantly influence decisions regarding the use of levosimendan for VA-ECMO weaning.
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Affiliation(s)
- Omar Ellouze
- Department of Anesthesia and Critical CareUniversity Hospital of DijonDijonFrance
| | | | - Mohamed Radhouani
- Department of Anesthesia and Critical CareUniversity Hospital of DijonDijonFrance
| | - Osama Abou‐Arab
- Department of Anesthesia and Critical CareUniversity Hospital of AmiensAmiensFrance
| | - Emmanuel Besnier
- Department of Anesthesia and Critical CareUniversity Hospital of RouenRouenFrance
| | - Mouhamed Moussa
- Department of Anesthesia and Critical CareUniversity Hospital of LilleLilleFrance
| | - Amélie Cransac
- Department of PharmacyUniversity Hospital of DijonDijonFrance
| | - Elea Ksiazek
- Direction of Clinical ResearchUniversity Hospital of DijonDijonFrance
| | | | - Paul Michel Mertes
- Department of Anesthesia and Critical CareUniversity Hospital of StrasbourgStrasbourgFrance
| | - Belaid Bouhemad
- Department of Anesthesia and Critical CareUniversity Hospital of DijonDijonFrance
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Gaisendrees C, Vollmer M, Walter SG, Djordjevic I, Eghbalzadeh K, Kaya S, Elderia A, Ivanov B, Gerfer S, Kuhn E, Sabashnikov A, Kahlert HA, Deppe AC, Kröner A, Mader N, Wahlers T. Management of out-of hospital cardiac arrest patients with extracorporeal cardiopulmonary resuscitation in 2021. Expert Rev Med Devices 2021; 18:179-188. [PMID: 33538204 DOI: 10.1080/17434440.2021.1886076] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
INTRODUCTION Over the last decade, eCPR programs have become more and more popular, at least amongst high-volume centers. Despite its rise in popularity and promising outcome, strategies concerning pre- and post-implantation of VA-ECMO remain at least debatable. Besides, integrating the appropriate set-up, managing anticoagulation, implementing LV-venting, and predicting neurological outcome play important roles in caring for thise highly selective patient-collective. We sought to present our institutional´s techniques for establishing an eCPR program and managing patients peri- and post implantation in eCPR-runs. AREAS COVERED This manuscript covers the majority of clinical concerns and parameters for establishing an eCPR program and its recent advantages. We will describe a safe way of cannulation, setting anticoagulation goals, strategies for LV-venting and ICU-treatment. Also included, an elaboration on neurological and cardiac prognostication. EXPERT OPINION We advocate ultrasound-guided cannula placement in eCPR patients. Also, we emphasize the importance of using stiffer wires and smaller arterial cannula sizes due to the different physiological parameters of OHCA patients. After cannulation, we aim for lower flow goals, the concept of 'partial VA-ECMO,' and lower anticoagulatory targets. LV-venting with Impella should remain an individual case to case decision.
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Affiliation(s)
- Christopher Gaisendrees
- Department of Cardiothoracic Surgery, University Hospital of Cologne, the City is Cologne (Köln), Germany
| | - Matias Vollmer
- Department of Cardiothoracic Surgery, University Hospital of Cologne, the City is Cologne (Köln), Germany
| | - Sebastian G Walter
- Department of Cardiothoracic Surgery, University Hospital of Cologne, the City is Cologne (Köln), Germany
| | - Ilija Djordjevic
- Department of Cardiothoracic Surgery, University Hospital of Cologne, the City is Cologne (Köln), Germany
| | - Kaveh Eghbalzadeh
- Department of Cardiothoracic Surgery, University Hospital of Cologne, the City is Cologne (Köln), Germany
| | - Süreyya Kaya
- Department of Cardiothoracic Surgery, University Hospital of Cologne, the City is Cologne (Köln), Germany
| | - Ahmed Elderia
- Department of Cardiothoracic Surgery, University Hospital of Cologne, the City is Cologne (Köln), Germany
| | - Borko Ivanov
- Department of Cardiothoracic Surgery, University Hospital of Cologne, the City is Cologne (Köln), Germany
| | - Stephen Gerfer
- Department of Cardiothoracic Surgery, University Hospital of Cologne, the City is Cologne (Köln), Germany
| | - Elmar Kuhn
- Department of Cardiothoracic Surgery, University Hospital of Cologne, the City is Cologne (Köln), Germany
| | - Anton Sabashnikov
- Department of Cardiothoracic Surgery, University Hospital of Cologne, the City is Cologne (Köln), Germany
| | - Heike A Kahlert
- Department of Cardiothoracic Surgery, University Hospital of Cologne, the City is Cologne (Köln), Germany
| | - Antje C Deppe
- Department of Cardiothoracic Surgery, University Hospital of Cologne, the City is Cologne (Köln), Germany
| | - Axel Kröner
- Department of Cardiothoracic Surgery, University Hospital of Cologne, the City is Cologne (Köln), Germany
| | - Navid Mader
- Department of Cardiothoracic Surgery, University Hospital of Cologne, the City is Cologne (Köln), Germany
| | - Thorsten Wahlers
- Department of Cardiothoracic Surgery, University Hospital of Cologne, the City is Cologne (Köln), Germany
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North M, Eckman P, Samara M, Chavez I, Schmidt C, Garberich R, Hryniewicz K. Peak troponin predicts successful weaning from VA ECMO in patients with acute myocardial infarction complicated by cardiogenic shock. Int J Artif Organs 2021; 45:68-74. [PMID: 33530814 DOI: 10.1177/0391398821991155] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND In patients treated for refractory cardiogenic shock (RCS) following acute myocardial infarction (AMI), predicting successful weaning from veno-arterial extracorporeal membrane oxygenation (VA ECMO) has important implications for decision-making and prognosis. METHODS We performed a retrospective review of adult VA ECMO patients with RCS complicating AMI at our institution from 2010 to 2019. We evaluated use of peak troponin I as a predictor of successful decannulation. RESULTS Sixty-two patients were analyzed; mean age 61.1 ± 9.8 years, 73% males, 62% presented with STEMI. Forty-five patients were successfully weaned (group I). Seventeen patients did not wean (group II); seven patients received a durable LVAD, 10 died. Patients from group I had significantly lower peak troponin I (89 vs 434 ng/mL, p = 0.0001). Receiver operating characteristic curves showed a peak troponin I cutoff of 400 ng/mL correctly classified patients by weaning status 90% of the time, with associated sensitivity of 71% and specificity of 98%. With each 50 ng/mL increase in troponin I, the likelihood of weaning decreased by 33%. CONCLUSIONS Peak troponin I above 400 ng/mL may be helpful in predicting unsuccessful weaning from VA ECMO support for refractory cardiogenic shock following myocardial infarction and facilitate triage decisions regarding need for advanced therapies.
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Affiliation(s)
- Monique North
- Minneapolis Heart Institute Foundation, Minneapolis, MN, USA
| | - Peter Eckman
- Minneapolis Heart Institute, Abbott Northwestern Hospital, Minneapolis, MN, USA
| | - Michael Samara
- Minneapolis Heart Institute, Abbott Northwestern Hospital, Minneapolis, MN, USA
| | - Ivan Chavez
- Minneapolis Heart Institute, Abbott Northwestern Hospital, Minneapolis, MN, USA
| | | | - Ross Garberich
- Minneapolis Heart Institute Foundation, Minneapolis, MN, USA
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12
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Mihama T, Bahatyrevich N, Cavarocchi N, Hirose H. Outcomes of end-organ function and survival with veno-arterial extracorporeal membrane oxygenation. Perfusion 2020; 36:808-813. [PMID: 33198559 DOI: 10.1177/0267659120969288] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Extracorporeal Membrane Oxygenation (ECMO) is a temporary therapy option for refractory cardiac or respiratory failure. Preliminary study suggests that ECMO aids in the recovery of end-organ function by maintaining systemic perfusion. METHODS A retrospective IRB approved database research and chart review was performed on patients initiated on veno-arterial (VA-) ECMO between September 2010 and April 2019. End-organ injury markers were compared between the pre-ECMO period, defined as markers recorded before ECMO initiation, and the pre-decannulation period, defined as markers prior to ECMO decannulation. Data was expressed with mean ± standard deviation, or median [quartile 1, quartile 3] and compared between Pre-ECMO and per-decannulation period. RESULTS Among the 159 VA-ECMO patients, 100 patients (63%) survived ECMO with mean ECMO duration 10 ± 7 days. Within the survival group, 78 patients (49%) weaned to recovery, and 22 patients (14%) weaned off to durable implantable devices. Compared to the pre-ECMO period, the pre-decannulation period significantly improved in pH (7.23 ± 0.19 vs. 7.40 ± 0.09; p < 0.001) and lactate (5.5 [2.3, 9.0] vs. 1.6 [0.9, 2.3]; p < 0.001), and serum creatinine (1.4 [1.1, 2.1] vs. 1.1 [0.8, 1.7]; p < 0.001). Significant changes were noted in ventilation parameters as well, such as FiO2 (100 [100, 100] vs. 50 [50, 50]; p < 0.001), PaO2 (88 [62, 135], 126 [87, 162]; p < 0.001) and PEEP (8.0 [5.0, 12.0] vs. 5.0 [5.0, 8.0]; p < 0.001). CONCLUSION Maintaining perfusion with VA-ECMO utilization on indicated patients demonstrated improvements in end-organ functions. Survival rates of VA-ECMO patients were also optimistic.
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Affiliation(s)
- Toru Mihama
- Department of Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | | | | | - Hitoshi Hirose
- Department of Surgery, Thomas Jefferson University, Philadelphia, PA, USA
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Mariscalco G, El-Dean Z, Yusuff H, Fux T, Dell'Aquila AM, Jónsson K, Ragnarsson S, Fiore A, Dalén M, di Perna D, Gatti G, Juvonen T, Zipfel S, Perrotti A, Bounader K, Alkhamees K, Loforte A, Lechiancole A, Pol M, Spadaccio C, Pettinari M, De Keyzer D, Welp H, Maselli D, Lichtenberg A, Ruggieri VG, Biancari F. Duration of Venoarterial Extracorporeal Membrane Oxygenation and Mortality in Postcardiotomy Cardiogenic Shock. J Cardiothorac Vasc Anesth 2020; 35:2662-2668. [PMID: 33250434 DOI: 10.1053/j.jvca.2020.11.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Revised: 11/01/2020] [Accepted: 11/02/2020] [Indexed: 12/15/2022]
Abstract
OBJECTIVE The optimal duration of venoarterial extracorporeal membrane oxygenation (VA-ECMO) in patients affected by postcardiotomy cardiogenic shock (PCS) remains controversial. The present study was conducted to investigate the effect of VA-ECMO duration on hospital outcomes. DESIGN Retrospective analysis of an international registry. SETTING Multicenter study including 19 tertiary university hospitals. PARTICIPANTS Between January 2010 and March 2018, data on PCS patients receiving VA-ECMO were retrieved from the multicenter PC-ECMO registry. INTERVENTIONS Patients were stratified according to the following different durations of VA-ECMO therapy: ≤three days, four-to-seven days, eight-to-ten days, and >ten days. MEASUREMENTS AND MAIN RESULTS A total of 725 patients, with a mean age of 62.9 ± 12.9 years, were included. The mean duration of VA-ECMO was 7.1 ± 6.3 days (range 0-39 d), and 39.4% of patients were supported for ≤three days, 29.1% for four-seven days, 15.3% for eight-ten days, and finally 20.7% for >ten days. A total of 391 (53.9%) patients were weaned from VA-ECMO successfully; however, 134 (34.3%) of those patients died before discharge. Multivariate logistic regression showed that prolonged duration of VA-ECMO therapy (four-seven days: adjusted rate 53.6%, odds ratio [OR] 0.28, 95% confidence interval [CI] 0.18-0.44; eight-ten days: adjusted rate 61.3%, OR 0.51, 95% CI 0.29-0.87; and >ten days: adjusted rate 59.3%, OR 0.49, 95% CI 0.31-0.81) was associated with lower risk of mortality compared with VA-ECMO lasting ≤three days (adjusted rate 78.3%). Patients requiring VA-ECMO therapy for eight-ten days (OR 1.96, 95% CI 1.15-3.33) and >10 days (OR 1.85, 95% CI 1.14-3.02) had significantly greater mortality compared with those on VA-ECMO for 4 to 7 days. CONCLUSIONS PCS patients weaned from VA-ECMO after four-seven days of support had significantly less mortality compared with those with shorter or longer mechanical support.
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Affiliation(s)
- Giovanni Mariscalco
- Department of Intensive Care Medicine and Cardiac Surgery, Glenfield Hospital, University Hospitals of Leicester NHS Trust, Leicester, United Kingdom.
| | - Zein El-Dean
- Department of Intensive Care Medicine and Cardiac Surgery, Glenfield Hospital, University Hospitals of Leicester NHS Trust, Leicester, United Kingdom
| | - Hakeem Yusuff
- Department of Intensive Care Medicine and Cardiac Surgery, Glenfield Hospital, University Hospitals of Leicester NHS Trust, Leicester, United Kingdom
| | - Thomas Fux
- Department of Molecular Medicine and Surgery, Department of Cardiac Surgery, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Angelo M Dell'Aquila
- Department of Cardiothoracic Surgery, Münster University Hospital, Münster, Germany
| | - Kristján Jónsson
- Department of Cardiac Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
| | | | - Antonio Fiore
- Department of Cardiothoracic Surgery, Henri Mondor University Hospital, AP-HP, Paris-Est University, Créteil, France
| | - Magnus Dalén
- Department of Molecular Medicine and Surgery, Department of Cardiac Surgery, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Dario di Perna
- Division of Cardiothoracic and Vascular Surgery, Robert Debré University Hospital, Reims, France
| | - Giuseppe Gatti
- Division of Cardiac Surgery, Ospedali Riuniti, Trieste, Italy
| | - Tatu Juvonen
- Heart and Lung Center, Helsinki University Hospital, Helsinki, Finland; Research Unit of Surgery, Anesthesiology and Critical Care, Faculty of Medicine, University of Oulu, Oulu, Finland
| | | | - Andrea Perrotti
- Department of Thoracic and Cardio-Vascular Surgery, University Hospital Jean Minjoz, Besançon, France
| | - Karl Bounader
- Division of Cardiothoracic and Vascular Surgery, Pontchaillou University Hospital, Rennes, France
| | | | - Antonio Loforte
- Department of Cardiothoracic, Transplantation and Vascular Surgery, S. Orsola Hospital, University of Bologna, Bologna, Italy
| | | | - Marek Pol
- Institute of Clinical and Experimental Medicine, Prague, Czech Republic
| | - Cristiano Spadaccio
- Department of Cardiothoracic Surgery, Golden Jubilee National Hospital, Glasgow, United Kingdom
| | - Matteo Pettinari
- Department of Cardiovascular Surgery, Ziekenhuis Oost-Limburg, Genk, Belgium
| | - Dieter De Keyzer
- Department of Cardiovascular Surgery, Ziekenhuis Oost-Limburg, Genk, Belgium
| | - Henryk Welp
- Department of Cardiothoracic Surgery, Münster University Hospital, Münster, Germany
| | | | - Artur Lichtenberg
- Department of Cardiovascular Surgery, Universitätsklinikum Düsseldorf, Düsseldorf, Germany
| | - Vito G Ruggieri
- Division of Cardiothoracic and Vascular Surgery, Robert Debré University Hospital, Reims, France
| | - Fausto Biancari
- Heart and Lung Center, Helsinki University Hospital, Helsinki, Finland; Research Unit of Surgery, Anesthesiology and Critical Care, Faculty of Medicine, University of Oulu, Oulu, Finland; Department of Surgery, University of Turku, Turku, Finland
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