Early and Long-Term Outcomes after Direct Bridge-to-Transplantation with Extracorporeal Membrane Oxygenation

Background: Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) as direct bridge-to-transplantation (dBTT) remains controversial. We compared the short- and long-term outcomes of adult patients undergoing urgent heart transplantation (HT) with (dBTT) and without (non-BTT) VA-ECMO support at the time of HT. Methods: Adults who underwent urgent HT in two institutions were assessed (N = 133; dBTT: N = 34 and non-BTT: N = 99). Patient characteristics, donor characteristics, in-hospital outcomes, and overall survival were compared. Mean follow up was 77±38 months and was 100% complete. Mortality predictors were identified using univariate and multivariate analyses. Results: Before HT, patients with dBTT had higher rates of ischemic cardiomyopathy, acute kidney injury, liver failure, respiratory failure, and longer graft ischemia times. More patients in the dBTT group had complications, such as requiring VA-ECMO postoperatively (dBTT=50% vs. non-BTT=20%, P < 0.01). Hospital deaths (dBTT=23% vs. non-BTT=19%, P = 0.58), one-year (74% vs. 80%) and five-year survival (62% vs. 75%, P = 0.74 for overall survival) were not significantly different. The MELD-XI score and previous cardiac surgery were independent predictors of hospital mortality. Conclusion: Direct bridge-to-transplantation in patients on VA-ECMO support was not associated with worse long-term outcomes compared with non-VA-ECMO urgent HT, especially in recipients without any associated organ failure and a low MELD-XI score before HT.

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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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Hemostasis, coagulation and thrombin in venoarterial and venovenous extracorporeal membrane oxygenation: the HECTIC study

Scientific Reports ◽

10.1038/s41598-021-87026-z ◽

2021 ◽

Vol 11 (1) ◽

Author(s):

Bruce Cartwright ◽

Hannah M. Bruce ◽

Geoffrey Kershaw ◽

Nancy Cai ◽

Jad Othman ◽

...

Keyword(s):

Extracorporeal Membrane Oxygenation ◽

Thrombin Generation ◽

Thrombotic Event ◽

Patient Characteristics ◽

Ecmo Support ◽

University Hospital ◽

Heparin Dose ◽

Membrane Oxygenation ◽

Thrombotic Complications ◽

Va Ecmo

AbstractExtracorporeal membrane oxygenation (ECMO) support has a high incidence of both bleeding and thrombotic complications. Despite clear differences in patient characteristics and pathologies between veno-venous (VV) and veno-arterial (VA) ECMO support, anticoagulation practices are often the same across modalities. Moreover, there is very little data on their respective coagulation profiles and comparisons of thrombin generation in these patients. This study compares the coagulation profile and thrombin generation between patients supported with either VV and VA ECMO. A prospective cohort study of patients undergoing VA and VV ECMO at an Intensive care department of a university hospital and ECMO referral centre. In addition to routine coagulation testing and heparin monitoring per unit protocol, thromboelastography (TEG), multiplate aggregometry (MEA), calibrated automated thrombinography (CAT) and von-Willebrand’s activity (antigen and activity ratio) were sampled second-daily for 1 week, then weekly thereafter. VA patients had significantly lower platelets counts, fibrinogen, anti-thrombin and clot strength with higher d-dimer levels than VV patients, consistent with a more pronounced consumptive coagulopathy. Thrombin generation was higher in VA than VV patients, and the heparin dose required to suppress thrombin generation was lower in VA patients. There were no significant differences in total bleeding or thrombotic event rates between VV and VA patients when adjusted for days on extracorporeal support. VA patients received a lower median daily heparin dose 8500 IU [IQR 2500–24000] versus VV 28,800 IU [IQR 17,300–40,800.00]; < 0.001. Twenty-eight patients (72%) survived to hospital discharge; comprising 53% of VA patients and 77% of VV patients. Significant differences between the coagulation profiles of VA and VV patients exist, and anticoagulation strategies for patients of these modalities should be different. Further research into the development of tailored anticoagulation strategies that include the mode of ECMO support need to be completed.

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Early and Long-Term Outcomes after Direct Bridge-to-Transplantation with Extracorporeal Membrane Oxygenation

The Journal of Heart and Lung Transplantation ◽

10.1016/j.healun.2021.01.392 ◽

2021 ◽

Vol 40 (4) ◽

pp. S124

Author(s):

M. Hébert ◽

P. Noly ◽

Y. Lamarche ◽

I. Bouhout ◽

M. Mauduit ◽

...

Keyword(s):

Extracorporeal Membrane Oxygenation ◽

Bridge To Transplantation ◽

Long Term Outcomes ◽

Membrane Oxygenation

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Long-term outcomes after extracorporeal membrane oxygenation in patients with dialysis-requiring acute kidney injury: A cohort study

PLoS ONE ◽

10.1371/journal.pone.0212352 ◽

2019 ◽

Vol 14 (3) ◽

pp. e0212352 ◽

Cited By ~ 4

Author(s):

Shao-Wei Chen ◽

Yueh-An Lu ◽

Cheng-Chia Lee ◽

An-Hsun Chou ◽

Victor Chien-Chia Wu ◽

...

Keyword(s):

Acute Kidney Injury ◽

Cohort Study ◽

Extracorporeal Membrane Oxygenation ◽

Kidney Injury ◽

Long Term Outcomes ◽

Membrane Oxygenation

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Abstract 16543: Severe Thrombocytopenia is Common in Adults Undergoing Venoarterial Extracorporeal Membrane Oxygenation and is Predictive of Hemorrhage

Circulation ◽

10.1161/circ.142.suppl_3.16543 ◽

2020 ◽

Vol 142 (Suppl_3) ◽

Author(s):

Tia C Kohs ◽

Vikram Raghunathan ◽

Patricia Liu ◽

Ramin Amirsoltani ◽

Michael Oakes ◽

...

Keyword(s):

Overall Survival ◽

Logistic Regression ◽

Platelet Count ◽

Extracorporeal Membrane Oxygenation ◽

Clinical Implications ◽

Severe Thrombocytopenia ◽

Multivariate Logistic Regression ◽

Membrane Oxygenation ◽

Increased Risk ◽

Va Ecmo

Introduction: Extracorporeal membrane oxygenation (ECMO) is used to provide circulatory support and facilitate gas exchange via cardiopulmonary bypass. The relationship between ECMO and the incidence of severe thrombocytopenia (platelet count <50 x 10 9 /L) and subsequent clinical consequences are ill defined. We aimed to identify the risk factors for the development of thrombocytopenia and its clinical implications. Methods: This is a single-center retrospective cohort study of adults who received venoarterial (VA) ECMO. We examined consecutive platelet counts while on ECMO. Univariate logistic regression was used to determine if mean platelet count, platelet count range, or severe thrombocytopenia were predictors of overall survival, hemorrhage and thrombosis. A multivariate logistic regression model was used to identify factors that contribute to the development of the aforementioned patient outcomes. Results: In our cohort, 33 patients were included with a mean age of 55 years and duration of ECMO of 5.9 days. All patients received heparin, 33.3% received antiplatelet therapy and 45.5% developed severe thrombocytopenia. In univariate, analysis the development of severe thrombocytopenia increased the odds of major bleeding by 450% (OR 5.500, 95% CI 1.219 - 24.813, P -value 0.027), and the odds of surviving hospitalization decreased 84.1% (OR 0.159, 95% CI 0.033 - 0.773, P -value 0.023). Multivariate logistic regression controlling for additional clinical variables found no significant association between the development of severe thrombocytopenia and rates of thrombosis, hemorrhage, or overall survival. Platelet count decreased over time while on ECMO. Conclusions: Nearly half of the patients requiring VA-ECMO developed severe thrombocytopenia, which was associated with an increased risk of hemorrhage and in-hospital mortality. Additional studies are required to clarify the clinical implications of severe thrombocytopenia in ECMO patients.

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