The importance of timing in postcardiotomy venoarterial extracorporeal membrane oxygenation: A descriptive multicenter observational study

Mariani, Silvia; Wang, I-wen; van Bussel, Bas C.T.; Heuts, Samuel; Wiedemann, Dominik; Saeed, Diyar; van der Horst, Iwan C.C.; Pozzi, Matteo; Loforte, Antonio; Boeken, Udo; Samalavicius, Robertas; Bounader, Karl; Hou, Xiaotong; Bunge, Jeroen J.H.; Buscher, Hergen; Salazar, Leonardo; Meyns, Bart; Herr, Daniel; Matteucci, Sacha; Sponga, Sandro; Ramanathan, Kollengode; Russo, Claudio; Formica, Francesco; Sakiyalak, Pranya; Fiore, Antonio; Camboni, Daniele; Raffa, Giuseppe Maria; Diaz, Rodrigo; Jung, Jae-Seung; Belohlavek, Jan; Pellegrino, Vin; Bianchi, Giacomo; Pettinari, Matteo; Barbone, Alessandro; Garcia, José P.; Shekar, Kiran; Whitman, Glenn; Lorusso, Roberto; Ravaux, Justine; Schaefer, Ann-Kristin; Conci, Luca; Szalkiewicz, Philipp; Khalil, Jawad; Lehmann, Sven; Obadia, Jean-Francois; Kalampokas, Nikolaos; Flecher, Erwan; Miranda, Dinis Dos Reis; Sriranjan, Kogulan; Mazzeffi, Michael A.; Vedadi, Nazli; Di Eusanio, Marco; MacLaren, Graeme; Sorokin, Vitaly; Costetti, Alessandro; Schmid, Chistof; Castillo, Roberto; Mikulenka, Vladimir; Solinas, Marco

doi:10.1016/j.jtcvs.2023.04.042

Cited by 11 publications

(1 citation statement)

References 46 publications

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“…The Post-cardiotomy Extra-Corporeal Life Support Study (PELS-1) collected data on adults suffering from post-cardiotomy cardiogenic shock and requiring ECLS support in cardiac surgery units worldwide. 9 The present article reports the results of a survey conducted among PELS-1 participating centers to highlight similarities and differences in terms of five key issues: (1) Characteristics of PC-ECLS hospitals; (2) Anticoagulation management and transfusion; (3) Left ventricular (LV) unloading; (4) Distal limb perfusion; (5) General ECLS monitoring practices.…”

Section: Introductionmentioning

confidence: 99%

Heterogeneity in clinical practices for post‐cardiotomy extracorporeal life support: A pilot survey from the PELS‐1 multicenter study

et al. 2023

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BackgroundHigh‐quality evidence for post‐cardiotomy extracorporeal life support (PC‐ECLS) management is lacking. This study investigated real‐world PC‐ECLS clinical practices.MethodsThis cross‐sectional, multi‐institutional, international pilot survey explored center organization, anticoagulation management, left ventricular unloading, distal limb perfusion, PC‐ECLS monitoring, and transfusion practices. Twenty‐nine questions were distributed among 34 hospitals participating in the Post‐cardiotomy Extra‐Corporeal Life Support Study.ResultsOf the 32 centers [16 low‐volume (50%); 16 high‐volume (50%)] that responded, 16 (50%) had dedicated ECLS specialists. Twenty‐six centers (81.3%) reported using additional mechanical circulatory supports. Anticoagulation practices were highly heterogeneous: 24 hospitals (75%) reported using patients bleeding status as a guide, without a specific threshold in 54.2% of cases. Transfusion targets ranged from 7 to 10 g/dL. Most centers used cardiac venting on a case‐by‐case basis (78.1%) and regular distal limb perfusion (84.4%). Nineteen (54.9%) centers reported dedicated monitoring protocols, including daily echocardiography (87.5%), Swan‐Ganz catheterization (40.6%), cerebral near‐infrared spectroscopy (53.1%), and multimodal assessment of limb ischemia. Inspection of the circuit (71.9%), oxygenator pressure drop (68.8%), plasma free hemoglobin (75%), d‐dimer (59.4%), lactate dehydrogenase (56.3%), and fibrinogen (46.9%) are used to diagnose hemolysis and thrombosis.ConclusionsThis study shows remarkable heterogeneity in clinical practices for PC‐ECLS management. More standardized protocols and better implementation of the available evidence are recommended.

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Section: Introductionmentioning

confidence: 99%

Heterogeneity in clinical practices for post‐cardiotomy extracorporeal life support: A pilot survey from the PELS‐1 multicenter study

et al. 2023

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The absolute lactate levels versus clearance for prognostication of post‐cardiotomy patients on veno‐arterial ECMO

Laimoud,

Machado,

et al. 2024

ESC Heart Failure

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AimsVeno‐arterial extracorporeal membrane oxygenation (VA‐ECMO) is a life‐saving procedure for supporting patients with cardiogenic shock after cardiac surgery. This work aimed to analyse the impact of changes in blood lactate levels on the survival of patients on post‐cardiotomy ECMO (PC‐ECMO) and whether lactate clearance (LC) performs better than absolute lactate levels.Methods and ResultsWe retrospectively analysed the data of adult patients who received PC‐ECMO at our centre between 2016 and 2022. The primary outcome was the in‐hospital mortality rate. Arterial lactate levels were measured at ECMO initiation, peak and 12 and 24 h after VA‐ECMO support. LC was calculated at 12 and 24 h. Out of 2368 patients who received cardiac surgeries, 152 (median age, 48 years; 57.9% of them were men) received PC‐ECMO. Of them, 48 (31.6%) survived and were discharged, while 104 (68.4%) died during the index hospitalization. Non‐survivors had higher frequencies of atrial fibrillation (41.35% vs. 12.5%, P < 0.001), chronic kidney disease (26.9% vs. 6.3%, P = 0.004), prolonged cardiopulmonary bypass (237 vs. 192 min, P = 0.016) and aortic cross‐clamping times (160 vs. 124 min, P = 0.04) than survivors. Non‐survivors had a significantly higher median Sequential Organ Failure Assessment (SOFA) score at ECMO initiation (13.5 vs. 9, P < 0.001) and a lower median Survival After Veno‐arterial ECMO (SAVE) score (−3 vs. 3, P < 0.001) with higher SAVE classes (P < 0.001) than survivors. After 12 h of VA‐ECMO support, the blood lactate level was negatively correlated with LC in survivors (r = −0.755, P < 0.001) and non‐survivors (r = −0.601, P < 0.001). After 24 h, the same negative correlation was identified between survivors (r = −0.764, P < 0.001) and non‐survivors (r = −0.847, P < 0.001). Blood lactate levels measured at 12 h to determine hospital mortality [>8.2 mmol/L, area under the receiver operating characteristic curve (AUROC): 0.868] and 24 h (>2.6 mmol/L, AUROC: 0.896) had the best performance, followed by LC‐T12 (<21.94%, AUROC: 0.807), LC‐T24 (<40.3%, AUROC: 0.839) and peak blood lactate (>14.35 mmol/L, AUROC: 0.828). The initial pre‐ECMO blood lactate (>6.25 mmol/L, AUROC: 0.731) had an acceptable ability to discriminate mortality but was less than the following measurements and clearance. Kaplan–Meier curves demonstrated that LC of <21.94% at T12 h and <40.3% at T24 h was associated with decreased survival (log‐rank P < 0.001). Cox proportional hazards regression analysis for mortality revealed that LC of <21.94% at T12 h had an adjusted hazard ratio (HR) of 2.73 [95% confidence interval (CI): 1.64–5.762, P < 0.001] and LC of <40.3% at T24 h had an adjusted HR of 1.98 (95% CI: 1.46–4.173, P < 0.001). The predictors of hospital mortality after PC‐ECMO were the lactate level at 12 h [odds ratio (OR): 1.67, 95% CI: 1.121–2.181, P = 0.001], initial SOFA score (OR: 1.593, 95% CI: 1.15–2.73, P < 0.001), initial blood lactate (OR: 1.21, 95% CI: 1.016–1.721, P = 0.032) and atrial fibrillation (OR: 6.17, 95% CI: 2.37–57.214, P = 0.003). Bivariate models using lactate levels and clearance at the same points revealed that blood lactate levels performed better than the clearance percentage.ConclusionsSerial measurements of arterial blood lactate and LC help in obtaining early prognostic guidance in adult patients supported by VA‐ECMO after cardiac surgery. Absolute lactate levels, compared with LC at the same time points, demonstrated better performance in differentiating mortality.

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Mechanical Circulatory Support During Surgical Revascularization for Ischemic Cardiomyopathy

Singh,

Vinogradsky,

Kirschner

et al. 2024

The Annals of Thoracic Surgery

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The importance of timing in postcardiotomy venoarterial extracorporeal membrane oxygenation: A descriptive multicenter observational study

Cited by 11 publications

References 46 publications

Heterogeneity in clinical practices for post‐cardiotomy extracorporeal life support: A pilot survey from the PELS‐1 multicenter study

Heterogeneity in clinical practices for post‐cardiotomy extracorporeal life support: A pilot survey from the PELS‐1 multicenter study

The absolute lactate levels versus clearance for prognostication of post‐cardiotomy patients on veno‐arterial ECMO

Mechanical Circulatory Support During Surgical Revascularization for Ischemic Cardiomyopathy

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