TCT-699 Outcomes of Venoarterial Extracorporeal Membrane Oxygenation (VA-ECMO) Support for Cardiogenic Shock in a large, Tertiary Care Advanced Heart Failure and Transplant Referral Center From 2013-2017

Since mechanical circulatory support (MCS) devices have become integral component in the therapy of refractory cardiogenic shock (RCS), we identified 67 patients in biventricular support with Impella and venoarterial Extracorporeal Membrane Oxygenation (VA-ECMO) for RCS between February 2013 and December 2019 and evaluated the risk factors of mortality in this setting. Mean age was 61.07 ± 10.7 and 54 (80.6%) patients were male. Main cause of RCS was acute myocardial infarction (AMI) (74.6%), while 44 (65.7%) were resuscitated prior to admission. The mean Simplified Acute Physiology Score II (SAPS II) and Sequential Organ Failure Assessment Score (SOFA) score on admission was 73.54 ± 16.03 and 12.25 ± 2.71, respectively, corresponding to an expected mortality of higher than 80%. Vasopressor doses and lactate levels were significantly decreased within 72 h on biventricular support (p < 0.05 for both). Overall, 17 (25.4%) patients were discharged to cardiac rehabilitation and 5 patients (7.5%) were bridged successfully to ventricular assist device implantation, leading to a total of 32.8% survival on hospital discharge. The 6-month survival was 31.3%. Lactate > 6 mmol/L, vasoactive score > 100 and pH < 7.26 on initiation of biventricular support, as well as Charlson comorbity index > 3 and prior resuscitation were independent predictors of survival. In conclusion, biventricular support with Impella and VA-ECMO in patients with RCS is feasible and efficient leading to a better survival than predicted through traditional risk scores, mainly via significant hemodynamic improvement and reduction in lactate levels.

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Use of Venoarterial Extracorporeal Membrane Oxygenation (VA-ECMO) in an Adult Patient with Septic and Cardiogenic Shock

Cardiovascular Surgery ◽

10.1007/978-3-319-57084-6_28 ◽

2018 ◽

pp. 325-339

Author(s):

Henrique Louzan Machado ◽

Leonardo Jadyr Silva Rodrigues Alves ◽

Helmgton José Brito de Souza

Keyword(s):

Extracorporeal Membrane Oxygenation ◽

Cardiogenic Shock ◽

Adult Patient ◽

Membrane Oxygenation ◽

Venoarterial Extracorporeal Membrane Oxygenation ◽

Va Ecmo

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Efficacy of left ventricular unloading strategies during venoarterial extracorporeal membrane oxygenation in patients with cardiogenic shock: a protocol for a systematic review and Bayesian network meta-analysis

BMJ Open ◽

10.1136/bmjopen-2020-047046 ◽

2021 ◽

Vol 11 (10) ◽

pp. e047046

Author(s):

Pengbin Zhang ◽

Shilin Wei ◽

Kerong Zhai ◽

Jian Huang ◽

Xingdong Cheng ◽

...

Keyword(s):

Extracorporeal Membrane Oxygenation ◽

Cardiogenic Shock ◽

Bayesian Network ◽

Meta Analysis ◽

Left Ventricular ◽

Cochrane Library ◽

Membrane Oxygenation ◽

Venoarterial Extracorporeal Membrane Oxygenation ◽

Patient Consent ◽

Va Ecmo

IntroductionVenoarterial extracorporeal membrane oxygenation (VA-ECMO) has been widely used for patients with refractory cardiogenic shock. A common side effect of this technic is the resultant increase in left ventricular (LV) afterload which could potentially aggravate myocardial ischaemia, delay ventricular recovery and increase the risk of pulmonary congestion. Several LV unloading strategies have been proposed and implemented to mitigate these complications. However, it is still indistinct that which one is the best choice for clinical application. This Bayesian network meta-analysis (NMA) aims to compare the efficacy of different LV unloading strategies during VA-ECMO.Methods and analysisPubMed, Embase, the Cochrane Library and the International Clinical Trials Registry Platform will be explored from their inception to 31 December 2020. Random controlled trials and cohort studies that compared different LV unloading strategies during VA-ECMO will be included in this study. The primary outcome will be in-hospital mortality. The secondary outcomes will include neurological complications, haemolysis, bleeding, limb ischaemia, renal failure, gastrointestinal complications, sepsis, duration of mechanical ventilation, length of intensive care unit and hospital stays. Pairwise and NMA will respectively be conducted using Stata (V.16, StataCorp) and Aggregate Data Drug Information System (V.1.16.5), and the cumulative probability will be used to rank the included LV unloading strategies. The risk of bias will be conducted using the Cochrane Collaboration’s tool or Newcastle-Ottawa Quality Assessment Scale according to their study design. Subgroup analysis, sensitivity analysis and publication bias assessment will be performed. The Grading of Recommendations Assessment, Development and Evaluation will be conducted to explore the quality of evidence.Ethics and disseminationEither ethics approval or patient consent is not necessary, because this study will be based on literature. The results will be disseminated through peer-reviewed publications and conference presentations.PROSPERO registration numberCRD42020165093.

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Ten thousand kilometre transfer of cardiogenic shock patients on venoarterial extracorporeal membrane oxygenation for emergency heart transplantation: Cooperation between Reunion Island and Metropolitan France

European Heart Journal Acute Cardiovascular Care ◽

10.1177/2048872617719652 ◽

2017 ◽

Vol 7 (4) ◽

pp. 371-378 ◽

Cited By ~ 6

Author(s):

Clément Charon ◽

Jérôme Allyn ◽

Bruno Bouchet ◽

Fréderic Nativel ◽

Eric Braunberger ◽

...

Keyword(s):

Extracorporeal Membrane Oxygenation ◽

Cardiogenic Shock ◽

Heart Transplantation ◽

Adult Patients ◽

Long Term Results ◽

Reunion Island ◽

Membrane Oxygenation ◽

Venoarterial Extracorporeal Membrane Oxygenation ◽

Réunion Island ◽

Va Ecmo

Background: There is no heart transplantation centre on the French overseas territory of Reunion Island (distance of 10,000 km). The aim of this study was to describe the characteristics of cardiogenic shock adult patients on venoarterial extracorporeal membrane oxygenation (VA-ECMO) who were transferred from Reunion Island to mainland France for emergency heart transplantation. Methods: This retrospective observational study was conducted between 2005 and 2015. The characteristics and outcome of cardiogenic shock patients on VA-ECMO were compared with those of cardiogenic shock patients not on VA-ECMO. Results: Thirty-three cardiogenic shock adult patients were transferred from Reunion Island to Paris for emergency heart transplantation. Among them, 19 (57.6%) needed mechanical circulatory support in the form of VA-ECMO. Median age was 51 (33–57) years and 46% of the patients had ischaemic heart disease. Patients on VA-ECMO presented higher Sequential Organ Failure Assessment score ( p = 0.03). No death occurred during the medical transfer by long flight, while severe complications occurred in 10 patients (30.3%). Incidence of thromboembolic events, severe infectious complications and major haemorrhages was higher in the group of patients on VA-ECMO than in the group of patients not on VA-ECMO ( p <0.01). Seven patients from the VA-ECMO group (36.8%) and six patients from the non-VA-ECMO group (42.9%, p=0.7) underwent heart transplantation after a median delay of 10 (4–29) days on the emergency waiting list. After heart transplantation, one-year survival rates were 85.7% for patients on VA-ECMO and 83.3% for patients not on VA-ECMO ( p=0.91). Conclusions: This study suggests the feasibility of very long-distance medical evacuation of cardiogenic shock patients on VA-ECMO for emergency heart transplantation, with acceptable long-term results.

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Left Ventricular Unloading Is Associated With Lower Mortality in Patients With Cardiogenic Shock Treated With Venoarterial Extracorporeal Membrane Oxygenation

Circulation ◽

10.1161/circulationaha.120.048792 ◽

2020 ◽

Vol 142 (22) ◽

pp. 2095-2106 ◽

Cited By ~ 1

Author(s):

Benedikt Schrage ◽

Peter Moritz Becher ◽

Alexander Bernhardt ◽

Hiram Bezerra ◽

Stefan Blankenberg ◽

...

Keyword(s):

Extracorporeal Membrane Oxygenation ◽

Cardiogenic Shock ◽

Left Ventricular ◽

Lower Mortality ◽

Severe Bleeding ◽

Complication Rates ◽

Matched Cohort ◽

Membrane Oxygenation ◽

Venoarterial Extracorporeal Membrane Oxygenation ◽

Va Ecmo

Background: Venoarterial extracorporeal membrane oxygenation (VA-ECMO) is increasingly used to treat cardiogenic shock. However, VA-ECMO might hamper myocardial recovery. The Impella unloads the left ventricle. This study aimed to evaluate whether left ventricular unloading in patients with cardiogenic shock treated with VA-ECMO was associated with lower mortality. Methods: Data from 686 consecutive patients with cardiogenic shock treated with VA-ECMO with or without left ventricular unloading using an Impella at 16 tertiary care centers in 4 countries were collected. The association between left ventricular unloading and 30-day mortality was assessed by Cox regression models in a 1:1 propensity score–matched cohort. Results: Left ventricular unloading was used in 337 of the 686 patients (49%). After matching, 255 patients with left ventricular unloading were compared with 255 patients without left ventricular unloading. In the matched cohort, left ventricular unloading was associated with lower 30-day mortality (hazard ratio, 0.79 [95% CI, 0.63–0.98]; P =0.03) without differences in various subgroups. Complications occurred more frequently in patients with left ventricular unloading: severe bleeding in 98 (38.4%) versus 45 (17.9%), access site–related ischemia in 55 (21.6%) versus 31 (12.3%), abdominal compartment in 23 (9.4%) versus 9 (3.7%), and renal replacement therapy in 148 (58.5%) versus 99 (39.1%). Conclusions: In this international, multicenter cohort study, left ventricular unloading was associated with lower mortality in patients with cardiogenic shock treated with VA-ECMO, despite higher complication rates. These findings support use of left ventricular unloading in patients with cardiogenic shock treated with VA-ECMO and call for further validation, ideally in a randomized, controlled trial.

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A retrospective cohort analysis of percutaneous versus side-graft perfusion techniques for veno-arterial extracorporeal membrane oxygenation in patients with refractory cardiogenic shock

Perfusion ◽

10.1177/0267659116683792 ◽

2016 ◽

Vol 32 (5) ◽

pp. 363-371 ◽

Cited By ~ 5

Author(s):

Mehmet Cakici ◽

Evren Ozcinar ◽

Cagdas Baran ◽

Ahmet Onat Bermede ◽

Mehmet Cahit Sarıcaoglu ◽

...

Keyword(s):

Extracorporeal Membrane Oxygenation ◽

Cardiogenic Shock ◽

Femoral Artery ◽

Vascular Complications ◽

Ecmo Support ◽

Acute Limb Ischemia ◽

Membrane Oxygenation ◽

Refractory Cardiogenic Shock ◽

Cannulation Site ◽

Va Ecmo

Objectives: This study was designed to compare vascular complications and the outcomes of ultrasound (US)-guided percutaneous cannulation with distal perfusion catheter (PC-DP) and arterial side-graft perfusion (SGP) techniques in patients who require veno-arterial extracorporeal membrane oxygenation (VA-ECMO) support for refractory cardiogenic shock (RCS). Methods: We conducted a retrospective, observational cohort study of consequtive patients with RCS treated with VA-ECMO at a single transplant center from March 2010 until August 2015. Overall, 148 patients underwent VA-ECMO for RCS (99 men, aged 56.6 ± 12.0 years; BSA, 1.85 ± 0.19). Patients were categorized based on VA-ECMO perfusion technique into PC-DP via femoral artery and SGP via axillary/femoral artery groups. Results: The median duration of VA-ECMO support was 5 days (range, 8 hours–80 days). Hospital mortality (PC-DP group, 54.7%; SGP group, 64.4%; p=0.23) and overall ECMO survival (PC-DP group, 36.9%; SGP group, 32.2%; p=0.47) was similar between the groups. There were no significant between-group differences in the rate of acute limb ischemia (PC-DP group, 4/75, 5.3%; SGP group, 2/73, 2.7%; p=0.68). However, the rate of surgical/cannulation site bleeding (PC-DP, 9/75 (12%) vs SGP, 18/73 (24.7%), p=0.05) and hyperperfusion syndrome (PC-DP, 2/75 (2.7%) vs SGP, 22/73 (30.1%),p=0.001) were higher in the SGP group than in the PC-DP group. Conclusions: We observed no significant difference in major vascular complications or survival between patients who underwent the PC-DP technique and those who underwent arterial SGP.

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Venoarterial extracorporeal membrane oxygenation for cardiogenic shock: a retrospective analysis based on the etiology of shock

The VAD Journal ◽

10.14434/vad.v3i0.27974 ◽

2017 ◽

Author(s):

Andrew Burchett ◽

Thomas Tribble ◽

Richard Charnigo ◽

Susan Smyth ◽

Maya Guglin

Keyword(s):

Pulmonary Embolism ◽

Cardiogenic Shock ◽

Retrospective Analysis ◽

Hospital Discharge ◽

Reference Group ◽

Ecmo Support ◽

Uniform System ◽

Venoarterial Extracorporeal Membrane Oxygenation ◽

Significant Difference ◽

Va Ecmo

Background We performed a retrospective analysis to evaluate the efficacy of VA-ECMO support in cardiogenic shock based on various etiologies. Methods We retrospectively analyzed 99 patients supported with VA-ECMO from January 1, 2012 to January 1, 2015. Outcomes included survival to discontinuation of VA-ECMO support and survival to hospital discharge. The etiologies of cardiogenic shock included cardiac arrest (CPR), acute myocardial infarction (AMI), decompensated congestive heart failure (CHF), pulmonary embolism (PE), right ventricular failure (RVF) not secondary to an acute pulmonary embolism, and post-cardiotomy syndrome (PCS). The PCS group was used as a reference group; odds ratios were estimated and Fisher’s exact tests were performed to compare each other group to the reference. Results Patients supported with VA-ECMO due to PE and CHF had better survival to hospital discharge (83.3% and 54.2%, with p = 0.003 and p = 0.011, respectively) versus the PCS group (7.7%). The PE, CHF, and AMI groups had statistically improved survival to VA-ECMO discontinuation. There was no statistically significant difference in survival to VA-ECMO discontinuation or hospital discharge in four subgroup analyses. Conclusions Patients supported with VA-ECMO in cardiogenic shock due to PE or CHF demonstrated increased rates of survival to hospital discharge when compared to the PCS group. This study also highlights the need for a more uniform system of categorizing etiologies of cardiogenic shock.

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Venoarterial Extracorporeal Membrane Oxygenation in Cardiogenic Shock: Lifeline of Modern Day CICU

Journal of Intensive Care Medicine ◽

10.1177/0885066619894541 ◽

2019 ◽

pp. 088506661989454

Author(s):

Aniket S. Rali ◽

Jonathan Chandler ◽

Andrew Sauer ◽

Michael A. Solomon ◽

Zubair Shah

Keyword(s):

Extracorporeal Membrane Oxygenation ◽

Cardiogenic Shock ◽

Mechanical Circulatory Support ◽

Treatment Modalities ◽

Circulatory Support ◽

Steady Increase ◽

Membrane Oxygenation ◽

Cardiopulmonary Support ◽

Venoarterial Extracorporeal Membrane Oxygenation ◽

Va Ecmo

Cardiogenic shock (CS) portends an extremely high mortality of nearly 50% during index hospitalization. Prompt diagnoses of CS, its underlying etiology, and efficient implementation of treatment modalities, including mechanical circulatory support (MCS), are critical especially in light of such high predicted mortality. Venoarterial extracorporeal membrane oxygenation (VA-ECMO) provides the most comprehensive cardiopulmonary support in critically ill patients and hence has seen a steady increase in its utilization over the past decade. Hence, a good understanding of VA-ECMO, its role in treatment of CS, especially when compared with other temporary MCS devices, and its complications are vital for any critical care cardiologist. Our review of VA-ECMO aims to provide the same.

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P5739Venoarterial Extracorporeal Membrane Oxygenation in Cardiogenic Shock: exploring prognostic variables and risk prediction tools

European Heart Journal ◽

10.1093/eurheartj/ehz746.0679 ◽

2019 ◽

Vol 40 (Supplement_1) ◽

Author(s):

P M Goncalves Teixeira ◽

M Passos Silva ◽

D Mbala ◽

M Ana Canelas ◽

M Varela ◽

...

Keyword(s):

Logistic Regression ◽

Regression Analysis ◽

Extracorporeal Membrane Oxygenation ◽

Hospital Mortality ◽

Cardiogenic Shock ◽

Sofa Score ◽

Ecmo Support ◽

Risk Scores ◽

Short Term ◽

Va Ecmo

Abstract Introduction The use of venoarterial extracorporeal membrane oxygenation (VA-ECMO) to support patients in cardiogenic shock has been increasing in Portugal over the past few years. Nonetheless, epidemiologic, prognostic and clinical outcome data are scarce. Purpose We aim to identify clinical variables with prognostic significance in this challenging population, as well as the performance of various risk scores in mortality prediction. Methods All patients that underwent VA-ECMO support at our Cardiac ICU between 2011 and 2018 were included in the analysis. Logistic regression analysis was used to assess the relationship between clinical variables and outcomes. Results Short-term mechanical support with VA-ECMO was given to 40 patients, with a mean age of 52±11 years. At the time of the implant, the mean SOFA score was 11.2±4.0, and mean SAVE score was −4.75±4.6. Mean ECMO support duration was 116±96 hours. In 70% (N=28) of patients, VA-ECMO was successfully weaned. In-hospital mortality was observed in 52.5% of patients, which was in accordance with the predicted mortality by SOFA score (22.5% to 82% in our population risk range) and by SAVE score (60 to 70%). Those who placed the VA-ECMO as a bridge to transplant or to long-term mechanical LV assist device had greater in-hospital mortality rates (91.6 vs 41.9%, p=0.013), as well as those under ≥2 inotropic/vasopressors (69.2 vs 21.4%, p=0.012) or when adrenaline use was needed (100% vs 44.1%, p=0.01). No other between-group differences were observed in what concerns short-term mortality. After logistic regression analysis, independent predictors of in-hospital mortality included AMI setting, number of vasoactive amines used, and necessity of a LV venting device. SAVE score had the greater predictive ability in these patients (AUC = 0.638) among the most utilized clinical risk scores (SOFA score AUC = 0.37; APACHE II score AUC = 0.59; SAPS II score AUC = 0.54). Conclusion In our analysis, patients in profound cardiogenic shock on VA-ECMO support had slightly better survival rates than predicted by classical Risk Scores. The SAVE score may be the most accurate tool to predict in-hospital mortality in this specific, and yet heterogeneous, clinical subset. Other well recognized clinical markers of severity may also help refine short-term prognosis, and potentially improve organ transplant or other destination therapy prioritization.

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