Postcardiotomy VA-ECMO for refractory cardiogenic shock

Abstract

Postcardiotomy cardiogenic shock (PCCS) is a rare but catastrophic syndrome that can occur following separation from cardiopulmonary bypass or at any time during the immediate postoperative course. The management of PCCS varies between clinicians, institutions and countries. The available evidence to guide this practice is limited. In their systematic review and meta-analysis, Khorsandi and colleagues report a synthesis of case-series pertinent to the use of venoarterial extracorporeal membrane oxygenation (VA-ECMO) for PCCS. Whilst we acknowledge the potential survival benefit for carefully selected patients for what is ordinarily a condition with high mortality, we wish to comment on several aspects of the study in the context of its application to clinical practice.Keywords: Postcardiotomy, VA-EMO, Systematic review, Cardiogenic shockIn their systematic review and meta-analysis of venoarterial extracorporeal membrane oxygenation (VA-ECMO) for postcardiotomy cardiogenic shock (PCCS), Khorsandi and colleagues report a pooled survival to hospital discharge of 30.8% and suggest a number of adverse prognostic indicators [1]. Whilst we agree that postcardiotomy VA-ECMO for refractory cardiogenic shock does indeed provide a significant survival benefit, we wish to highlight several limitations so as to aid interpretation of this study and inform future analyses.With regards the search strategy, it was unclear from which database(s) (Medline and/or PubMed) articles were retrieved and from when the search extends. A recent Cochrane review advised against the pooling of studies from prior to 2000 due to significant advances in technology, yet three of the included studies are from the 1990s [2]. The use of other databases, a Google™ search and searching the bibliography of included manuscripts could have ensured a more comprehensive strategy. With regards inclusion and exclusion criteria, all transplant and non-transplant patients receiving VA-ECMO for postcardiotomy cardiogenic shock were included. At our institution, it is generally more common for VA-ECMO to be employed following heart transplantation than it is following non-transplant cardiac surgery. Anecdotally, we also find that outcomes following planned VA-ECMO use following heart transplantation are better as compared to unplanned non-transplant postcardiotomy VA-ECMO. Given that transplant and non-transplant patients have very different baseline characteristics together with different pre, intra and postoperative courses, it may have been advisable to statistically treat transplant and non-transplant groups separately to further reduce data heterogeneity. The finding that all studies were observational in design and with many employing retrospective data collection, is shared by our systematic review of extracorporeal life support for postcardiotomy cardiogenic shock [3]. We also found considerable difficulty in retrieving all relevant articles due to variable definitions of PCCS and extracorporeal life support (ECLS) in the literature.With regards ...

Autologous mitochondrial transplantation for cardiogenic shock in pediatric patients following ischemia-reperfusion injury

“…7,8 Noncardiac complications are associated with ECMO support, and the incidence of such complications increases with the duration of ECMO support. 2,3,[5][6][7][8] It is possible that earlier institution of MT following IRI may lead to even shorter duration of ECMO support and thus improved mortality. In fact, in the setting of IRI, cellular changes triggered by myocardial ischemia, and exacerbated by reperfusion, lead to permanent compromise in myocardial function and cell viability.…”

“…Clinical outcomes in pediatric patients with postcardiotomy cardiogenic shock resulting from IRI remain poor, with the highest mortality rates or need for orthotopic heart transplantation (OHT) reported among patients requiring ECMO support. [1][2][3][4][5][6][7][8] We have previously demonstrated that intramyocardial transplantation of autologous mitochondria isolated from nonischemic skeletal muscle (ie, mitochondrial transplantation [MT]) is safe and is associated with recovery of myocardial function and improved cell viability in preclinical models of IRI. [9][10][11][12][13][14][15][16][17][18][19][20][21][22] Based on these initial results, we performed a pilot study to assess the effect of MT in a cohort of pediatric patients undergoing ECMO support for cardiogenic shock secondary to IRI after cardiac surgery 11 compared with a matched cohort of patients who did not receive MT.…”

Follow-up on ECMO after Cardiac Surgery: How Can We Evaluate Therapy?

“…It is possible to reduce it up to 40 % with VA-ECMO implantation [Nwozuzu 2016;Guihaire 2017]. There are still no concrete guidelines for implantation time and VA-ECMO management [Charlesworth 2017]. Many studies were designed to identify risk factors for mortality [Rastan 2010;Biancari 2018;Wang 2018].…”

A Clinical Update on Vasoactive Medication in the Management of Cardiogenic Shock

“… 3 , 20 Acute complications of AMI such as ventricular septal rupture, 21 LV free wall rupture, acute mitral regurgitation, and cardiac tamponade account for the other ischemic etiologies of cardiogenic shock. 3 Other non-ischemic etiologies 22 include valvular regurgitation and stenosis, aortic dissection, primary LV dysfunction like acute decompensated heart failure, post cardiotomy syndromes, 23 takotsubo cardiomyopathy, 24 , 25 myocarditis, infiltrative disorders 26 (like sarcoidosis, amyloidosis, hemochromatosis), acute tachyarrhythmia and bradyarrhythmia, 27 infective endocarditis, pericarditis and constrictive pericarditis. 28 Rare causes include severe hypertrophic obstructive cardiomyopathy, peri, and post-partum cardiomyopathy.…”