Predictors of Poor Outcomes in Pediatric Venoarterial Extracorporeal Membrane Oxygenation

Background: Venoarterial extracorporeal membrane oxygenation (VA-ECMO) provides respiratory and hemodynamic support to pediatric patients in severe cardiac failure. We aim to identify risk factors associated with poorer outcomes in this population. Methods: A retrospective chart review was conducted of pediatric patients requiring VA-ECMO support for cardiac indications at our institution from 2004 to 2015. Data were collected on demographics, indication, markers of cardiac output, ventricular assist device (VAD) insertion, heart transplantation, or left atrial (LA) decompression. Univariate Cox proportional hazards models were used to calculate hazard ratios (HRs) for variables associated with the composite primary outcome of transplant-free survival (TFS). Results: Of the 68 reviewed patients, 65% were male, 84% were white, 38% had a prior surgery, 13% had a prior transplant, 10% had a prior ECMO support, and 87.5% required vasoactive support within six hours of cannulation. The ECMO indications included congenital heart disease repaired >30 days prior (12%), cardiomyopathy (41%), posttransplant rejection (7%), and cardiorespiratory failure (40%). The TFS was 54.5% at discharge and 47.7% at one year. Predictors of transplant and/or death include epinephrine use (hazard ratio [HR] = 2.269, P = .041), elevated lactate (HR = 1.081, P = 0005), and elevated creatinine (HR = 1.081, P = .005) within six hours prior to cannulation. Sixteen (23.6%) patients underwent LA decompression. Placement of VAD occurred in 16 (23.5%) patients, for which nonwhite race (HR = 2.94, P = .034) and prior ECMO (HR = 3.42, P = .053) were the only identified risk factors. Conclusions: Need for VA-ECMO for cardiac support carries high inpatient morbidity and mortality. Epinephrine use and elevated lactate and creatinine were associated with especially poor outcomes. Patients who survived to discharge had good short-term follow-up results.

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Biventricular Unloading with Impella and Venoarterial Extracorporeal Membrane Oxygenation in Severe Refractory Cardiogenic Shock: Implications from the Combined Use of the Devices and Prognostic Risk Factors of Survival

Journal of Clinical Medicine ◽

10.3390/jcm10040747 ◽

2021 ◽

Vol 10 (4) ◽

pp. 747

Author(s):

Georgios Chatzis ◽

Styliani Syntila ◽

Birgit Markus ◽

Holger Ahrens ◽

Nikolaos Patsalis ◽

...

Keyword(s):

Risk Factors ◽

Extracorporeal Membrane Oxygenation ◽

Cardiogenic Shock ◽

Risk Scores ◽

Circulatory Support ◽

Membrane Oxygenation ◽

Venoarterial Extracorporeal Membrane Oxygenation ◽

Refractory Cardiogenic Shock ◽

Lactate Levels ◽

Va Ecmo

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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Extracorporeal membrane oxygenation outcomes in children with hemophagocytic lymphohistiocytosis

Perfusion ◽

10.1177/0267659116667804 ◽

2016 ◽

Vol 32 (2) ◽

pp. 151-156 ◽

Cited By ~ 3

Author(s):

Katherine Cashen ◽

Roland L Chu ◽

Justin Klein ◽

Peter T Rycus ◽

John M Costello

Keyword(s):

Risk Factors ◽

Extracorporeal Membrane Oxygenation ◽

Cardiac Failure ◽

Hemophagocytic Lymphohistiocytosis ◽

Pediatric Patients ◽

Life Support ◽

Extracorporeal Life Support ◽

Hemorrhagic Complication ◽

Membrane Oxygenation ◽

Va Ecmo

Introduction: Pediatric patients with hemophagocytic lymphohistiocytosis (HLH) may develop refractory respiratory or cardiac failure that warrants consideration for extracorporeal membrane oxygenation (ECMO) support. The purposes of this study were to describe the use and outcomes of ECMO in pediatric HLH patients, to identify risk factors for hospital mortality and to compare their ECMO use and outcomes to the ECMO population as a whole. Methods: Pediatric patients (⩽ 18 years) with a diagnosis of HLH in the Extracorporeal Life Support Organization (ELSO) Registry were included. Results: Between 1983 and 2014, data for 30 children with HLH were available in the ELSO registry and all were included in this study. All cases occurred in the last decade. Of the 30 HLH patients, 24 (80%) had a respiratory indication for ECMO and six (20%) had a cardiac indication (of which 4 were E-CPR and 2 cardiac failure). Of the 24 respiratory ECMO patients, 63% were placed on VA ECMO. Compared with all pediatric patients in the ELSO registry during the study period (n=17,007), HLH patients had worse hospital survival (non-HLH 59% vs HLH 30%, p=0.001). In pediatric HLH patients, no pre-ECMO risk factors for mortality were identified. The development of a hemorrhagic complication on ECMO was associated with decreased mortality (p=0.01). Comparing HLH patients with respiratory failure to patients with other immune compromised conditions, the overall survival rate is similar (HLH 38% vs. non-HLH immune compromised 31%, p=0.64). Conclusions: HLH is an uncommon indication for ECMO and these patients have increased mortality compared to the overall pediatric ECMO population. These data should be factored into decision-making when considering ECMO for pediatric HLH patients.

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Stroke During Extracorporeal Membrane Oxygenation: Timing, Risk Factors and Clinical Outcomes

10.21203/rs.3.rs-141344/v1 ◽

2021 ◽

Author(s):

Harim Kim ◽

Jeong Hoon Yang ◽

Chi Ryang Chung ◽

Kyeongman Jeon ◽

Gee Young Suh ◽

...

Keyword(s):

Risk Factors ◽

Extracorporeal Membrane Oxygenation ◽

Brain Injuries ◽

Medical Center ◽

Ecmo Support ◽

Membrane Oxygenation ◽

Significant Difference ◽

Stroke Group ◽

Va Ecmo ◽

Vv Ecmo

Abstract Background Among various complications of extracorporeal membrane oxygenation (ECMO), stroke continues to be a major factor that worsens the clinical outcome because it is associated with mortality and adverse neurologic outcomes. Appropriate risk evaluation, screening, and management of neurologic injury under ECMO support has not yet been established and requires further investigation. Thus, this study analyzes the stroke related risk factors and outcomes in order to determine the appropriate intervention to minimize neurologic sequalae while on ECMO. Method Total 1039 patients who underwent ECMO from January 2012 to September 2019 at the Samsung Medical Center were reviewed and 759 subjects were selected for the analysis. The exclusion criteria were age < 18y, failure of successful ECMO initiation, multiple ECMO runs, underlying severe brain injury, and incomplete medical records. Multivariate analysis was performed to identify the risk factors of strokes on ECMO support using cox proportional hazard regression. In order to analyze the timing of stroke after ECMO initiation, the Mann–Whitney U test and Kruskal–Wallis rank sum test were performed.Results Among The overall incidence of stroke was 5.1% (n = 39) without a significant difference between venoarterial (VA) and venovenous(VV) ECMO (5.3% and 4.8%, respectively, p = 0.480). Independent risk factors for stroke were intraaortic balloon pump (IABP, p = 0.0008) and a history of stroke (p = 0.0354). Most hypoxic brain injuries were found in the VA ECMO (93.3%), and 54.5% of intracranial hemorrhage were in the VV ECMO. Most patients with strokes (61.5%) were diagnosed within 72hours after ECMO initiation. The time taken for stroke event from the time of ECMO insertion was shorter in the VA ECMO than in the VV ECMO (median 1.5 vs. 3 days). The stroke group had a higher mortality rate than the non-stroke group (64.1% and 44.7%, respectively, p = 0.014). Conclusion Concurrent ECMO and IABP use may increase the incidence of stroke during ECMO support. Evaluation for stroke that includes CT within 72 hours of ECMO insertion may enable early diagnosis, allowing timely intervention.

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Venoarterial extracorporeal membrane oxygenation with or without simultaneous intra-aortic balloon pump support as a direct bridge to heart transplantation: results from a nationwide Spanish registry

Interactive CardioVascular and Thoracic Surgery ◽

10.1093/icvts/ivz155 ◽

2019 ◽

Vol 29 (5) ◽

pp. 670-677 ◽

Cited By ~ 4

Author(s):

Gonzalo Barge-Caballero ◽

María A Castel-Lavilla ◽

Luis Almenar-Bonet ◽

Iris P Garrido-Bravo ◽

Juan F Delgado ◽

...

Keyword(s):

Confidence Interval ◽

Extracorporeal Membrane Oxygenation ◽

Heart Transplantation ◽

Ecmo Support ◽

Control Group ◽

Intra Aortic Balloon Pump ◽

Membrane Oxygenation ◽

Venoarterial Extracorporeal Membrane Oxygenation ◽

Iabp Support ◽

Va Ecmo

Abstract OBJECTIVES To investigate the potential clinical benefit of an intra-aortic balloon pump (IABP) in patients supported with venoarterial extracorporeal membrane oxygenation (VA-ECMO) as a bridge to heart transplantation (HT). METHODS We studied 169 patients who were listed for urgent HT under VA-ECMO support at 16 Spanish institutions from 2010 to 2015. The clinical outcomes of patients under simultaneous IABP support (n = 73) were compared to a control group of patients without IABP support (n = 96). RESULTS There were no statistically significant differences between the IABP and control groups with regard to the cumulative rates of transplantation (71.2% vs 81.2%, P = 0.17), death during VA-ECMO support (20.6% vs 14.6%, P = 0.31), transition to a different mechanical circulatory support device (5.5% vs 5.2%, P = 0.94) or weaning from VA-ECMO support due to recovery (2.7% vs 0%, P = 0.10). There was a higher incidence of bleeding events in the IABP group (45.2% vs 25%, P = 0.006; adjusted odds ratio 2.18, 95% confidence interval 1.02–4.67). In-hospital postoperative mortality after HT was 34.6% in the IABP group and 32.5% in the control group (P = 0.80). One-year survival after listing for urgent HT was 53.3% in the IABP group and 52.2% in the control group (log rank P = 0.75). Multivariate adjustment for potential confounders did not change this result (adjusted hazard ratio 0.94, 95% confidence interval 0.56–1.58). CONCLUSIONS In our study, simultaneous IABP therapy in transplant candidates under VA-ECMO support did not significantly reduce morbidity or mortality.

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Right axillary artery cannulation for venoarterial extracorporeal membrane oxygenation: a retrospective single centre observational study

European Journal of Cardio-Thoracic Surgery ◽

10.1093/ejcts/ezaa397 ◽

2020 ◽

Author(s):

Angelo Pisani ◽

Wael Braham ◽

Carlotta Brega ◽

Moklhes Lajmi ◽

Sophie Provenchere ◽

...

Keyword(s):

Extracorporeal Membrane Oxygenation ◽

Axillary Artery ◽

Ecmo Support ◽

Control Group ◽

Emergency Setting ◽

Systemic Complications ◽

Artery Cannulation ◽

Membrane Oxygenation ◽

Venoarterial Extracorporeal Membrane Oxygenation ◽

Va Ecmo

Abstract OBJECTIVES Our goal was to assess the safety, outcomes and complication rate of axillary artery cannulation for venoarterial extracorporeal membrane oxygenation (VA-ECMO). METHODS A retrospective analysis was conducted on data obtained from the review of medical charts of all consecutive patients undergoing VA-ECMO implantation between January 2013 and December 2017 at a teaching hospital. Only patients with right axillary VA-ECMO implantation in a non-emergency setting were included. Post-procedural outcomes and local and systemic complications were analysed. RESULTS One hundred and seventy-four [131 male (75.3%), 43 female (24.7%); mean age 56.8 ± 15.1 years] patients underwent femoral-axillary VA-ECMO. Indications were cardiogenic shock from any cause (n = 78, 44.8%) or post-cardiotomy syndrome (n = 96, 55.2%). Fifty-three (30.5%) patients died while on VA-ECMO support. At the time of VA-ECMO ablation, 89 (51.1%) patients had recovered; 13 (7.5%) patients were bridged to a long-term mechanical support device and 19 (10.9%) patients underwent heart transplants. Thirty-day and 1-year mortality was 36.2% (n = 63) and 49.4% (n = 86), respectively. The 1-year survival rate of patients who were weaned from VA-ECMO support was 72.7% (n = 88). The complications of axillary cannulation were bleeding (n = 7, 4%), local infection (n = 3, 1.7%), upper limb ischaemia (n = 2, 1.1%) and brachial plexus injury (n = 1, 0.6%). Left ventricle unloading was required for 9 (5.2%) patients. The median duration of VA-ECMO support was 7 (range 1–26) days. CONCLUSIONS Right axillary artery cannulation is a safe and reliable method for VA-ECMO support with a low rate of local complications. In the absence of a control group with femoro-femoral cannulation, no definitive conclusion about the superiority of axillary over femoral cannulation can be drawn.

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Mild Hypothermia and Neurologic Outcomes in Patients undergoing Venoarterial Extracorporeal Membrane Oxygenation

10.22541/au.163793863.33478175/v1 ◽

2021 ◽

Author(s):

Sung-Min Cho ◽

Mais Al-Kawaz ◽

Benjamin Shou ◽

Rochelle Prokupets ◽

Glenn Whitman ◽

...

Keyword(s):

Extracorporeal Membrane Oxygenation ◽

Neurological Outcome ◽

Primary Outcome ◽

Mild Hypothermia ◽

Ecmo Support ◽

Membrane Oxygenation ◽

Venoarterial Extracorporeal Membrane Oxygenation ◽

Mean Temperature ◽

Va Ecmo ◽

The Impact

Background: Patients with venoarterial extracorporeal membrane oxygenation (VA-ECMO) are at risk of cerebral reperfusion injury after prolonged hypoperfusion and immediate restoration of systemic blood flow. We aimed to examine the impact of mild hypothermia during the first 24 hours post-ECMO on neurological outcome in VA-ECMO patients. Methods: This was a retrospective study of adult VA-ECMO patients from a tertiary care center. Mild hypothermia was defined as 32-36°C during the first 24 hours post-ECMO. Primary outcome was good neurological function at discharge measured by a modified Rankin Scale ≤3. Multivariable logistic regression analysis was performed for primary outcome adjusting for pre-specified covariates. Results: Overall, 128 consecutive patients with VA-ECMO support (median age: 60 years and 63% males) were included. Within the first 24 hours of VA-ECMO cannulation, we found a median of 71 readings per patient (interquartile range 45-88). Eighty-eight patients (68.8%) experienced mild hypothermia within the first 24 hours while 18 of those 88 patients (14.2%) had a mean temperature<36°C. ECMO indications included post-cardiotomy shock (39.8%), cardiac arrest (29.7%), and cardiogenic shock (26.6%). Duration of mild hypothermia, but not mean temperature, was independently associated with increased odds of good neurological outcome at discharge (Odds Ratio [OR]=1.16, 95% Confidence Interval [CI]=1.04-1.31, p=0.01) after adjusting for age, severity of illness, post-ECMO systemic hemorrhage, post-cardiotomy shock, acute brain injury, and mean 24-hour PaO . Neither duration of mild hypothermia (OR=0.93, CI=0.84-1.03, p=0.17) nor mean temperature (OR=0.78, CI=0.29-2.08, p=0.62) was significantly associated with mortality. Similarly, duration of mild hypothermia (p=0.47) and mean 24-hour temperature (p=0.76) were not significantly associated with frequency of systemic hemorrhages. Conclusions: In this single center study, longer duration of mild hypothermia during the first 24 hours of ECMO support was significantly associated with improved neurological outcome. Mild hypothermia was not associated with an increased risk of systemic hemorrhage or improved survival.

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Clinical Outcome and Risk Factors for Acute Fulminant Myocarditis Supported by Venoarterial Extracorporeal Membrane Oxygenation: an Analysis of Nationwide CSECLS Database in China Mainland

10.21203/rs.3.rs-739094/v1 ◽

2021 ◽

Author(s):

Tong Hao ◽

Yu Jiang ◽

Changde Wu ◽

Chenglong Li ◽

Chuang Chen ◽

...

Keyword(s):

Risk Factors ◽

Cardiac Arrest ◽

Extracorporeal Membrane Oxygenation ◽

Lactate Concentration ◽

Adult Patients ◽

Fulminant Myocarditis ◽

Membrane Oxygenation ◽

Venoarterial Extracorporeal Membrane Oxygenation ◽

Va Ecmo ◽

China Mainland

Abstract Purpose: To assess the outcomes and risk factors for adult patients with acute fulminant myocarditis supported with venoarterial extracorporeal membrane oxygenation (VA ECMO) in China mainland. Methods: Data were extracted from Chinese Society of ExtraCorporeal Life Support (CSECLS) Registry database. Data from adult patients who were diagnosed with acute myocarditis and needed VA ECMO in the database were retrospectively analyzed. The primary outcome was 90-day mortality after ECMO initiation in patients with acute fulminant myocarditis supported with VA ECMO. Cox proportional hazard regression model was used to examine the risk factors associated with 90-day mortality. Results: Among 221 patients enrolled, 186 (84.2%) patients weaned from ECMO and 159 (71.9%) patients survived to 90 days. The median age was 38 years (IQR 29-49) and males (n=115) accounted for 52.0% of the patients. The median ECMO duration was 134 hours (IQR 96-177hrs). The main adverse events during ECMO course was bleeding (16.3%), followed by infection (15.4%). In the multivariate Cox model, cardiac arrest prior to ECMO initiation (adjusted HR 2.529; 95%CI: 1.341-4.767, p =0.004), lower pH value (adjusted HR 0.016; 95%CI: 0.010-0.059, p <0.001) and higher lactate concentration at 24 hours after ECMO initiation (adjusted HR 1.146; 95%CI: 1.075-1.221, p <0.001) was associated with 90day mortality. Conclusions: In our study, 71.9% patients with acute fulminant myocarditis supported with VA ECMO survived to 90 days. Cardiac arrest prior to ECMO, lower pH and higher lactate concentration at 24 hours after ECMO initiation were correlated with 90-day mortality closely.ClinicalTrials.gov registration number: NCT04158479, Registered 8 November 2019, https://clinicaltrials.gov/ct2/show/NCT04158479?term=hou+xiaotong&draw=2&rank=2.

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