Value of Lactate Levels during ECMO Support for Refractory Cardiogenic Shock

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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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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Early and long-term outcomes of extracorporeal membrane oxygenation support in refractory cardiogenic shock for non-surgical patients: nine years experience at our Institute

European Heart Journal ◽

10.1093/ehjci/ehaa946.1846 ◽

2020 ◽

Vol 41 (Supplement_2) ◽

Author(s):

G St-Pierre ◽

L Laflamme ◽

E Charbonneau ◽

Y.T Sia

Keyword(s):

Extracorporeal Membrane Oxygenation ◽

Hospital Mortality ◽

Cardiogenic Shock ◽

Patient Selection ◽

Ecmo Support ◽

Long Term Outcomes ◽

Refractory Cardiogenic Shock ◽

Va Ecmo ◽

Cardiac Surgeons

Abstract Purpose Venoarterial extracorporeal membrane oxygenation (VA-ECMO) support is ultimately applied in refractory cardiogenic shock and is associated with high in-hospital mortality. We sought to describe the characteristics and analyze early and long-term outcomes of patients with refractory cardiogenic shock at our institution as well as our approach to patient selection. Methods This single-center retrospective study used the ECMO database from the cardiac surgery department to identify all patients with refractory cardiogenic shock at our Institute. VA-ECMO for patients with postcardiotomy shock, on-going cardiopulmonary resuscitation and venovenous ECMO were excluded. Primary endpoint was in-hospital mortality after VA-ECMO. Secondary outcomes were early complications on VA-ECMO and long-term survival after hospital discharge. Refractory cardiogenic shock was defined by either hypotension or end-organ failure despite adequate inotropic support. Results All patients with refractory cardiogenic shock were admitted to our cardiological ICU and our Heart team was systematically consulted. This team was mainly composed of transplant and LVAD cardiologists and cardiac surgeons specialized in ECMO. After case discussion, the decision for VA-ECMO implantation as a bridge therapy was made if the patient was deemed candidate to advance heart failure treatment. VA-ECMO was rapidly implanted by cardiac surgeons at bedside or in operating room with a median time from decision to implantation of 150 minutes (IQR: 100–233). Fifty-nine patients underwent VA-ECMO for refractory cardiogenic shock between 2010–2019. Patients were 52.1±14.5 years old, 75% were male and more than 90% were not known for any prior cardiac history. The indication for VA-ECMO support was acute myocardial infarction in 34 patients (58%) with reduced LVEF, mitral regurgitation, arrhythmia storm or ventricular septal defect. Myocarditis occurred in 19% of patients. The median LVEF was 13% (IQR: 10–31). Peripheral cannulation was most frequently implanted (92%). During VA-ECMO support, 43 patients survived and 16 patients died. Figure 1 shows weaning strategies for patients who survived VA-ECMO support. Of these, 37 patients survived up to discharge (86%). After a median follow-up of 2.9 years (IQR: 1.8–4.8), 92% were alive. The median time on VA-ECMO support was 4.9 days (IQR 3.5–7.6). Complications were bleeding needing reoperation (41%), pneumonia (41%), renal failure requiring dialysis (39%) and limb ischemia (17%). Conclusion In our experience, venoarterial ECMO is a feasible and acceptable alternative to support patients with refractory cardiogenic shock despite inotropic agents. Interestingly, the survival rate was particularly high as compared to the literature. This could be explained by patient selection and early VA-ECMO implantation. Evolution of patients after ECMO Funding Acknowledgement Type of funding source: None

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The clinical significance of blood lactate levels in evaluation of adult patients with veno-arterial extracorporeal membrane oxygenation

The Egyptian Heart Journal ◽

10.1186/s43044-020-00108-7 ◽

2020 ◽

Vol 72 (1) ◽

Author(s):

Mohamed Laimoud ◽

Mosleh Alanazi

Keyword(s):

Hospital Mortality ◽

Cardiogenic Shock ◽

Lactate Level ◽

Ecmo Support ◽

Adult Patients ◽

Care Hospital ◽

Arterial Lactate ◽

Lactate Levels ◽

Va Ecmo ◽

Arterial Lactate Level

Abstract Background Veno-arterial ECMO is a life-supporting procedure that can be done to the patients with cardiogenic shock which is associated with hyperlactatemia. The objective of this study was to detect the validity of serial measurements of arterial lactate level in differentiating hospital mortality and neurological outcome after VA-ECMO support for adult patients with cardiogenic shock. All consecutive patients ≥ 18 years admitted with cardiogenic shock and supported with VA-ECMO between 2015 and 2019 in our tertiary care hospital were retrospectively studied. Results The study included 106 patients with a mean age of 40.2 ± 14.4 years, a mean BMI of 26.5 ± 7 and mostly males (69.8%). The in-hospital mortality occurred in 56.6% and acute cerebral strokes occurred in 25.5% of the enrolled patients. The non-survivors and the patients with acute cerebral strokes had significantly higher arterial lactate levels at pre-ECMO initiation, post-ECMO peak and after 24 h of ECMO support compared to the survivors and those without strokes, respectively. The peak arterial lactate ≥ 14.65 mmol/L measured after ECMO support had 81.7% sensitivity and 89.1% specificity for predicting hospital mortality [AUROC 0.889, p < 0.001], while the arterial lactate level ≥ 3.25 mmol/L after 24 h of ECMO support had 88.3% sensitivity and 97.8% specificity for predicting hospital mortality [AUROC 0.93, p < 0.001]. The peak lactate ≥ 15.15 mmol/L measured after ECMO support had 70.8% sensitivity and 69% specificity for predicting cerebral strokes [AUROC 0.717, p < 0.001], while the lactate level ≥ 3.25 mmol/L after 24 h of ECMO support had 79.2% sensitivity and 72.4% specificity for predicting cerebral strokes [AUROC 0.779, p < 0.001]. Progressive hyperlactatemia (OR = 1.427, 95% CI 1.048–1.944, p = 0.024) and increasing SOFA score after 48 h (OR = 1.819, 95% CI 1.374–2.409, p < 0.001) were significantly associated with in-hospital mortality after VA-ECMO support. Post hoc analysis detected a significantly high frequency of hypoalbuminemia in the non-survivors and in the patients who developed acute cerebral strokes during VA-ECMO support. Conclusion Progressive hyperlactatemia after VA-ECMO initiation for adult patients with cardiogenic shock is a sensitive and specific predictor of hospital mortality and acute cerebrovascular strokes. According to our results, we could recommend early VA-ECMO initiation to achieve adequate circulatory support and better outcome.

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

Artificial Organs ◽

10.1111/aor.13331 ◽

2018 ◽

Vol 43 (2) ◽

pp. 132-141 ◽

Cited By ~ 4

Author(s):

Thomas Fux ◽

Manne Holm ◽

Matthias Corbascio ◽

Lars H. Lund ◽

Jan van der Linden

Keyword(s):

Cardiogenic Shock ◽

Ecmo Support ◽

Outcome Predictors ◽

Refractory Cardiogenic Shock ◽

Va Ecmo ◽

Nonsurgical Patients

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The clinical significance of blood lactate levels in evaluation of adult patients with Veno-Arterial Extracorporeal Membrane Oxygenation

European Heart Journal Acute Cardiovascular Care ◽

10.1093/ehjacc/zuab020.166 ◽

2021 ◽

Vol 10 (Supplement_1) ◽

Author(s):

M Laimoud ◽

M Alanazi

Keyword(s):

Hospital Mortality ◽

Cardiogenic Shock ◽

Lactate Level ◽

Ecmo Support ◽

Adult Patients ◽

Circulatory Support ◽

Arterial Lactate ◽

Lactate Levels ◽

Va Ecmo ◽

Arterial Lactate Level

Abstract Funding Acknowledgements Type of funding sources: None. Background Veno-Arterial ECMO is a life supporting procedure that can be done to the patients with cardiogenic shock which is associated with hyperlactatemia . The objective of this study was to detect the validity of serial measurements of arterial lactate level in differentiating hospital mortality and neurological outcome after VA-ECMO support. Results : This retrospective study included 106 patients between 2015 and 2019 with a mean age of 40.2 ± 14.4 years and mostly males (69.8%) . The in-hospital mortality occurred in 56.6% and acute strokes occurred in 25.5% of the patients . The non-survivors and the patients with acute strokes had significantly higher arterial lactate levels at pre-ECMO initiation , post-ECMO peak and after 24 hours of ECMO support compared to the survivors and those without strokes respectively. The peak arterial lactate ≥ 14.65 mmol/L measured after ECMO support had 81.7 % sensitivity and 89.1 % specificity for predicting hospital mortality [AUROC: 0.889 , p <0.001 ] while the arterial lactate level ≥ 3.25 mmol/L after 24 hours of ECMO support had 88.3% sensitivity and 97.8% specificity for predicting hospital mortality [AUROC: 0.93 , p <0.001 ]. The peak lactate ≥ 15.15 mmol/L measured after ECMO support had 70.8 % sensitivity and 69 % specificity for predicting cerebral strokes [AUROC: 0.717 , p <0.001 ] while the lactate level ≥ 3.25 mmol/L after 24 hours of ECMO support had 79.2% sensitivity and 72.4% specificity for predicting cerebral strokes [AUROC: 0.779, p <0.001 ]. Progressive hyperlactatemia (OR = 1.427 , 95% CI : 1.048 – 1.944 , p = 0.024 ) and increasing SOFA score after 48 hours (OR = 1.819 , 95% CI : 1.374 – 2.409 , p < 0.001) were significantly associated with in-hospital mortality after VA-ECMO support. Conclusion : Progressive hyperlactatemia after VA-ECMO initiation for adult patients with cardiogenic shock is a sensitive and specific predictor of hospital mortality and acute cerebrovascular strokes . According to our results , we could recommend early VA-ECMO initiation to achieve adequate circulatory support and better outcome. Predictors of hospital mortality.Studied variablesP valueOR95% CI for ORLactate peak0.0241.4271.048 - 1.944Hemodialysis0.3154.1260.344 - 51.669Atrial fibrillation0.073.2680.786 - 31.26Cardiac surgeries0.2173.4820.480 - 25.152Δ SOFA<0.0011.8191.374 - 2.409Central VA-ECMO0.123.9310.482 - 24.16Abstract Figure. ROC of lactate differentiating mortality

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Awake Implementation of Extracorporeal Life Support in Refractory Cardiogenic Shock

Medicina ◽

10.3390/medicina58010043 ◽

2021 ◽

Vol 58 (1) ◽

pp. 43

Author(s):

Julia Riebandt ◽

Thomas Haberl ◽

Klaus Distelmaier ◽

Martin H. Bernardi ◽

Anne-Kristin Schaefer ◽

...

Keyword(s):

Cardiogenic Shock ◽

Life Support ◽

Extracorporeal Life Support ◽

Venous Pressure ◽

Organ Function ◽

Central Venous ◽

Therapy Options ◽

Refractory Cardiogenic Shock ◽

Lactate Levels ◽

Organ Replacement

Background and objectives: Extracorporeal life support (ECLS) is a widely accepted and effective strategy for use in patients presenting with refractory cardiogenic shock. Implantation in awake and non-intubated patients allows for optimized evaluation of further therapy options while avoiding potential side effects associated with the need for sedation and intubation. The aim of the study was the assessment of safety and feasibility of awake ECLS implementation and of outcomes in patients treated with this concept. Materials and Methods: We retrospectively reviewed the concept of awake ECLS implantation in 16 consecutive patients (mean age 58 ± 8 years; male: 88%; ischemic cardiomyopathy: 50%) from 02/2017 to 01/2021. Study endpoints were survival to weaning or bridging to durable support or organ replacement and development of end-organ function and hemodynamic parameters on ECLS. Results: Fourteen patients (88%) were able to be successfully transitioned to definite therapy options. ECLS support stabilized end-organ function, led to a decrease in mean lactate levels (5.3 ± 3.7 mmol/L at baseline to 1.9 ± 1.3 mmol/L 12 h after ECLS start; p = 0.01) and improved hemodynamics (median central venous pressure 20 ± 5 mmHg vs. 10 ± 2 mmHg, p = 0.001) over a median duration of two days (1–8 days IQR). Two patients (13%) died on ECLS support due to multi-organ dysfunction syndrome. Survival to discharge of initially successfully bridged or weaned patients was 64%. Conclusions: Awake ECLS implantation is feasible and safe with the key advantage of omitting or delaying general anesthesia and intubation, with their associated risks in cardiogenic-shock patients, facilitating further decision making.

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