Clinical Outcomes of Early Extubation Strategy in Patients Undergoing Extracorporeal Membrane Oxygenation as a Bridge to Heart Transplantation

Abstract

Background Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) might be considered a bridge therapy in patients who are expected to have short waiting times for heart transplantation. We investigated the clinical outcomes of patients who underwent VA-ECMO as a bridge to heart transplantation and whether the deployment of an early extubation ECMO strategy is beneficial. Methods Between November 2006 and December 2018, we studied 102 patients who received VA-ECMO as a bridge to heart transplantation. We classified these patients into an early extubation ECMO group (n = 24) and a deferred extubation ECMO group (n = 78) based on the length of the intubated period on VA-ECMO (≤ 48 hours or > 48 hours). The primary outcome was in-hospital mortality. Results The median duration of early extubation VA-ECMO was 10.0 (4.3–17.3) days. The most common cause for patients to be put on ECMO was dilated cardiomyopathy (65.7%) followed by ischemic cardiomyopathy (11.8%). In-hospital mortality rates for the deferred extubation and early extubation groups, respectively, were 24.4% and 8.3% ( P = 0.147). During the study period, in the deferred extubation group, 60 (76.9%) underwent transplantation, while 22 (91.7%) underwent transplantation in the early extubation group. Delirium occurred in 83.3% and 33.3% of patients from the deferred extubation and early extubation groups ( P < 0.001) and microbiologically confirmed infection was identified in 64.1% and 41.7% of patients from the two groups ( P = 0.051), respectively. Conclusion VA-ECMO as a bridge therapy seems to be feasible for deployment in patients with a short waiting time for heart transplantation. Deployment of the early extubation ECMO strategy was associated with reductions in delirium and infection in this population.

Current applications and outcomes of venoarterial extracorporeal membrane oxygenation based on six years of experience. Risk factors for in-hospital mortality. A single-center retrospective study

“…In our study, the median time of mechanical ventilation to first extubation of all patients was 45 (2-918) hours, and 28% were extubated in less than 24 hours after ECMO implantation, which supports the adherence to the early extubation protocol, whenever possible. However, in line with the study by Youn et al, 26 the occurrences the most catastrophic adverse event among our patients with 100% hospital mortality.…”

“…The summary of the "Awake ECMO" strategy by Langer et al 25 describes several benefits of re duced mechanical ventilation time, with the key being the prevention of ventilator induced dia phragm dysfunction and ventilator associated pneumonia. Recently, Youn et al 26 reported in hospital mortality rates for deferred extubation (>48 hours) and early extubation (≤48 hours) in ECMO patients, as 24.4% and 8.3%, respective ly. In our study, the median time of mechanical ventilation to first extubation of all patients was 45 (2-918) hours, and 28% were extubated in less than 24 hours after ECMO implantation, which supports the adherence to the early extubation protocol, whenever possible.…”

Awake extracorporeal life support and physiotherapy in adult patients: A systematic review of the literature

“…The ECLS modality support, when reported, was venoarterial (V-V) in 56.8% (n = 619/1089) 14,[19][20][21][25][26][27]29,31,32,38,[40][41][42][43]45,47 of patients, veno-venous (V-A) in 39.6% (n = 431/1089) 14,19,[22][23][24]26,30,[32][33][34][35][38][39][40][42][43][44][45][46] of cases and only 3.9% (n = 39/1089) 26,30,32,38,40,44,45 of patients underwent other ECLS modalities. Cannulation strategy was reported in 931 cases (80.5% of the total population reviewed).…”

“…Main indications for ECLS support were BTR (n = 666, 36.6%) 19,[22][23][24][25][27][28][29][30][31][33][34][35]37,39,41,[43][44][45][46] and BTT (n = 472, 34.8%). 14,21,23,24,26,28,32,[35][36][37][38]40,42,[45][46][47] 14,34,38,39,41,46 and ranged 20-30.1.…”

“…Cannulation strategy was reported in 931 cases (80.5% of the total population reviewed). Femoral-femoral cannulation (n = 642/931) was received by 69% patients femoralfemoral cannulation (n = 642/931) with either unilateral or bilateral approach, 14,[19][20][21][22][23][25][26][27][28][29][30][31]33,34,37,[39][40][41][43][44][45][46] of which 75.9% for the specific reported cohort of V-A (n=284/374) and 63.5% for the specific reported cohort of V-V support mode (n=290/457). The 31% (n=289/931) of population underwent upper body cannulation through jugular and axillary access, 19,24,26,30,34,35,37,40,42,45,47 represented by 17.4% (n=65/374) of the specific reported V-A cases and 36.5% (n=167/457) of the V-V cases respectively.…”