Background. Venoarterial ECMO is increasingly used in resuscitation of adult patients with cardiogenic shock with variable mortality reports worldwide. Our objectives were to study the variables associated with hospital mortality in adult patients supported with VA-ECMO and to determine the validity of repeated assessments of those patients by the Sequential Organ Failure Assessment (SOFA) score for prediction of hospital mortality. We retrospectively studied adult patients admitted to the cardiac surgical critical care unit with cardiogenic shock supported with VA-ECMO from January 2015 to August 2019 in our tertiary care hospital. Results. One hundred and six patients supported with VA-ECMO were included in our study with in-hospital mortality of 56.6%. The mean age of studied patients was 40.2 ± 14.4 years, and the patients were mostly males (69.8%) with a mean BMI of 26.5 ± 7 without statistically significant differences between survivors and nonsurvivors. Presence of CKD, chronic atrial fibrillation, and cardiac surgeries was significantly more frequent in the nonsurvivors group. The nonsurvivors had more frequent AKI (p<0.001), more haemodialysis use (p<0.001), more gastrointestinal bleeding (p=0.039), more ICH (p=0.006), and fewer ICU days (p=0.002) compared to the survivors group. The mean peak blood lactate level was 11 ± 3 vs 16.7 ± 3.3, p<0.001, and the mean lactate level after 24 hours of ECMO initiation was 2.2 ± 0.9 vs 7.9 ± 5.7, p<0.001, in the survivors and nonsurvivors, respectively. Initial SOFA score ≥13 measured upon ICU admission had a 85% sensitivity and 73.9% specificity for predicting hospital mortality [AUROC = 0.862, 95% CI: 0.791–0.932; p<0.001] with 81% PPV, 79.1% NPV, and 80.2% accuracy while SOFA score ≥13 at day 3 had 100% sensitivity and 91.3% specificity for predicting mortality with 93.8% PPV, 100% NPV, and 96.2% accuracy [AUROC = 0.995, 95% CI: 0.986–1; p<0.001]. The ∆1 SOFA (3-1) ≥2 had 95% sensitivity and 93.5% specificity for predicting hospital mortality [AUROC = 0.958, 95% CI: 0.913–1; p<0.001] with 95% PPV, 93.5% NPV, and 94.3% accuracy. SOFA score ≥15 at day 5 had 98% sensitivity and 100% specificity for predicting mortality with 99% accuracy [AUROC = 0.994, 95% CI: 0.982–1; p<0.001]. The ∆2 SOFA (5-1) ≥2 had 90% sensitivity and 97.8% specificity for predicting hospital mortality [AUROC = 0.958, 95% CI: 0.909–1; p<0.001] with 97.8% PPV, 90% NPV, and 94.8% accuracy. Multivariable regression analysis revealed that increasing ∆1 SOFA score (OR = 2.506, 95% CI: 1.681–3.735, p<0.001) and increasing blood lactate level (OR = 1.388, 95% CI: 1.015–1.898, p=0.04) were significantly associated with hospital mortality after VA-ECMO support for adults with cardiogenic shock. Conclusion. The use of VA-ECMO in adult patients with cardiogenic shock is still associated with high mortality. Serial evaluation of those patients with SOFA score during the first few days of ECMO support is a good predictor of hospital mortality. Increase in SOFA score after 48 hours and hyperlactataemia are significantly associated with increased hospital mortality.

Background Veno-arterial ECMO is a life-supporting procedure that can be done to the patients with cardiogenic shock which is associated with hyperlactatemia. The objective of this study was to detect the validity of serial measurements of arterial lactate level in differentiating hospital mortality and neurological outcome after VA-ECMO support for adult patients with cardiogenic shock. All consecutive patients ≥ 18 years admitted with cardiogenic shock and supported with VA-ECMO between 2015 and 2019 in our tertiary care hospital were retrospectively studied. Results The study included 106 patients with a mean age of 40.2 ± 14.4 years, a mean BMI of 26.5 ± 7 and mostly males (69.8%). The in-hospital mortality occurred in 56.6% and acute cerebral strokes occurred in 25.5% of the enrolled patients. The non-survivors and the patients with acute cerebral strokes had significantly higher arterial lactate levels at pre-ECMO initiation, post-ECMO peak and after 24 h of ECMO support compared to the survivors and those without strokes, respectively. The peak arterial lactate ≥ 14.65 mmol/L measured after ECMO support had 81.7% sensitivity and 89.1% specificity for predicting hospital mortality [AUROC 0.889, p < 0.001], while the arterial lactate level ≥ 3.25 mmol/L after 24 h of ECMO support had 88.3% sensitivity and 97.8% specificity for predicting hospital mortality [AUROC 0.93, p < 0.001]. The peak lactate ≥ 15.15 mmol/L measured after ECMO support had 70.8% sensitivity and 69% specificity for predicting cerebral strokes [AUROC 0.717, p < 0.001], while the lactate level ≥ 3.25 mmol/L after 24 h of ECMO support had 79.2% sensitivity and 72.4% specificity for predicting cerebral strokes [AUROC 0.779, p < 0.001]. Progressive hyperlactatemia (OR = 1.427, 95% CI 1.048–1.944, p = 0.024) and increasing SOFA score after 48 h (OR = 1.819, 95% CI 1.374–2.409, p < 0.001) were significantly associated with in-hospital mortality after VA-ECMO support. Post hoc analysis detected a significantly high frequency of hypoalbuminemia in the non-survivors and in the patients who developed acute cerebral strokes during VA-ECMO support. Conclusion Progressive hyperlactatemia after VA-ECMO initiation for adult patients with cardiogenic shock is a sensitive and specific predictor of hospital mortality and acute cerebrovascular strokes. According to our results, we could recommend early VA-ECMO initiation to achieve adequate circulatory support and better outcome.

Background The use of extracorporeal membrane oxygenator (ECMO) support devices are associated with complications, including bleeding and thrombosis. Unfractionated heparin (UFH) is the gold standard anticoagulant in ECMO patients. Clinically, UFH is monitored through activated clotting time (ACT), activated partial thromboplastin time (aPTT), and anti–factor Xa assay. It is unknown which assay best predicts anticoagulation effects in adults. Objective To assess the correlation of UFH dosing and monitoring using an established protocol. Methods A pilot, prospective cohort, historically controlled study was conducted at a tertiary care hospital. Patients ≥18 years-old who received ECMO on the multifaceted anticoagulation protocol were included and compared with those on the conventional method of anticoagulation. The primary end point was to assess the correlation between UFH dose and different monitoring methods throughout 72 hours using the new protocol guided by ACT and anti–factor Xa assay. Results In each arm, 20 patients were enrolled. The study revealed that anti–factor Xa assay had the largest number of “strong” correlations 11/20 (55%), followed by both aPTT and aPTT ratio 10/20 (50%), and, finally, ACT 2/20 (10%). Concordance between anti–factor Xa assay and the other monitoring parameters in the prospective arm was generally low: 31% with aPTT ratio, 26% with ACT, and 23% with aPTT. Conclusion and Relevance The adaption of a multifaceted anticoagulation protocol using anti–factor Xa assay may provide a better prediction of heparin dosing in adults ECMO patients compared with the conventional ACT-based protocol. Further studies are needed to assess the safety and different monitoring modalities.

Background Despite the improved medical and surgical managements, still there is a significant risk of developing acute cerebrovascular strokes after coronary artery bypass grafting (CABG). Our objectives were to study the immediate and long-term outcomes after CABG and to identify the possible predictors of post-CABG strokes. Results Between January 2016 and August 2020, 410 adult patients, mostly males (82.2%), were retrospectively enrolled after CABG. Acute postoperative strokes occurred in 31 (7.5%) patients; of them, 30 (96.8%) patients had ischemic stroke, while 1 (3.2%) had hemorrhagic stroke. Mechanical thrombectomy was done in two cases. The patients who developed acute cerebral stroke had significantly higher admission (p = 0.02) and follow-up (p < 0.001) SOFA scores, higher arterial blood lactate level (p < 0.001), longer hospitalization (p < 0.001) and more hospital mortality (p < 0.001) compared with the patients who did not develop stroke. Kaplan–Meier curves for 5-year mortality showed increased risk in those patients with postoperative stroke (HR: 23.03; 95% CI: 6.10–86.92, p < 0.001). After multivariate regression, the predictors of early postoperative stroke were carotid artery stenosis (CAS), postoperative atrial fibrillation, cardiopulmonary bypass time, prior cerebral stroke, admission SOFA score and chronic kidney disease (CKD). The predictors of late cerebrovascular stroke were CAS, combined CABG and valve surgery, CKD, atrial fibrillation, prior stroke and HbA1c. Conclusions The development of post-CABG acute cerebrovascular stroke is associated with longer hospitalization, multiple morbidities and increased mortality. Careful assessment and management of risk factors especially atrial fibrillation and carotid artery stenosis should be implemented to decrease this substantial complication after CABG.

Our institutional experience of extracorporeal membrane oxygenator support for cardiac indications in adult patients indicates poor survival. It significantly increased costs by delaying imminent death and prolonging stay in the intensive care unit.