Contemporary Outcomes of Venoarterial Extracorporeal Membrane Oxygenation for Refractory Cardiogenic Shock at a Large Tertiary Care Center

Abstract

Refractory cardiogenic shock (RCS) is associated with significant morbidity and mortality, and current mainstays of medical therapy appear inadequate. Venoarterial extracorporeal membrane oxygenation (VA-ECMO) represents an increasingly accepted therapy for RCS. Demographics, past medical history, preoperative characteristics, outcomes, and adverse events were collected for consecutive patients who received VA-ECMO support for RCS at our institution from March 2007 to December 2013. One hundred and seventy-nine patients with a mean age of 56.9 ± 16.1 years were included. Etiologies of RCS included postcardiotomy shock in 70 patients (39%), acute myocardial infarction in 46 patients (26%), primary graft failure in 17 patients (10%), and acute decompensated heart failure in 24 patients (13%). Mean arterial pressure before VA-ECMO support was 59.4 ± 22.8 mm Hg and 30.7% (n = 55) were undergoing active cardiopulmonary resuscitation at the time of cannulation. Overall, 38.6% of patients (n = 69) survived to discharge and 44.7% of patients (n = 80) survived to 30 days. Myocardial recovery was achieved in 79.7% of survivors (n = 55) and 39.1% were transitioned to a more durable device. Univariate analysis identified age (p = 0.002) and etiology of RCS (p = 0.041) as the most significant predictors of in-hospital mortality. Venoarterial extracorporeal membrane oxygenation for RCS appears successful as salvage therapy. Age and etiology should be considered when evaluating patients for VA-ECMO.

VA‐ECMO Support in Nonsurgical Patients With Refractory Cardiogenic Shock: Pre‐Implant Outcome Predictors

“…Previous larger studies have presented a combination of nonsurgical and surgical patients including both predictors before and during VA‐ECMO , or have not reported rate of missing data or having substantially incomplete data . The largest and only single center study strictly addressing the impact of pre‐ECMO variables on outcome by Waha et.…”

“…Although RCS represents the majority of patients on VA‐ECMO , the majority of studies have focused on postcardiotomy patients . Remaining studies have evaluated nonsurgical subgroups or a combination of nonsurgical and surgical populations , which complicates interpretation as the two latter cohorts have different pathophysiological mechanisms. Independent pre‐VA‐ECMO outcome predictors in an unselected nonsurgical population with RCS have only scarcely been identified as studies have mainly included variables from both before and after initiation of VA‐ECMO in the analysis , or have not reported rates of missing data or having substantially incomplete data .…”

Importance of stratifying acute kidney injury in cardiogenic shock resuscitated with mechanical circulatory support therapy

“…Each modality differs in the device characteristics, insertion technique, associated surgical insult, postoperative management, and the indications, and the analyses of the individual devices were previously reported. 24 Our ST-VAD was inserted surgically, usually through a midline sternotomy with the use of cardiopulmonary bypass, whereas percutaneous ECMO is less invasive and used in sicker and more unstable patients. CS includes a certain spectrum of clinical presentation, and our strategy is to choose a device that seems most appropriate to the need of the individual patient.…”

Initiation and management of adult veno-arterial extracorporeal life support

“…The survival rates to discharge or transfer in these cohorts were 41% and 30%, respectively. A single institution series of 179 patients supported on VA-ECLS demonstrated a 39% survival rate to discharge, with 45% surviving to 30 days (4). Myocardial recovery was demonstrated in 80% of survivors and 39% were transitioned to a more durable device.…”