30-Day perioperative mortality following venoarterial extracorporeal membrane oxygenation for postcardiotomy cardiogenic shock in patients with normal preoperative ejection fraction

Abstract

OBJECTIVES Assessment of early outcomes in patients with normal preoperative left ventricular ejection fraction (LVEF) in whom venoarterial extracorporeal membrane oxygenation (VA-ECMO) was implanted for postcardiotomy cardiogenic shock (PCCS) during the first postoperative 48 h. METHODS Retrospective single-centre analysis in adult patients with normal LVEF, who received VA-ECMO support for PCCS from May 1998 to May 2018. The primary outcome was 30-day perioperative mortality during the index hospitalization. RESULTS A total of 62 125 adult patients underwent cardiac surgery at our institution during the study period. Among them, 173 patients (0.3%) with normal preoperative LVEF required VA-ECMO for PCCS. Among them, 71 (41.1%) patients presented PCCS due to coronary malperfusion and in 102 (58.9%) patients, no evident cause was found for PCCS. Median duration of VA-ECMO support was 5 days (interquartile range 2–8 days). A total of 135 (78.0%) patients presented VA-ECMO-related complications and the overall 30-day perioperative mortality was 57.8%. Independent predictors of mortality were: lactate level just before VA-ECMO implantation [odds ratio (OR) 1.27; P < 0.001], major bleeding during VA-ECMO (OR 3.76; P = 0.001), prolonged cardiopulmonary bypass time (OR 1.01; P < 0.001) and female gender (OR 4.87; P < 0.001). CONCLUSIONS Mortality rates of VA-ECMO in PCCS patients are high, even in those with preoperative normal LVEF. Coronary problems are an important cause of PCCS; however, the aetiology remains unknown in the vast majority of the cases. The implantation of VA-ECMO before development of tissue hypoperfusion and the control of VA-ECMO-associated complications are the most important prognostic factors in PCCS patients. Lactate levels may help guide timing of VA-ECMO implantation and define the extent of therapeutic effort.

Mortality in patients with normal left ventricular function requiring emergency VA-ECMO for postcardiotomy cardiogenic shock due to coronary malperfusion

“…The high 30-day mortality in our cohort again highlights the devastating nature of PCCS. Mortality rates are still high even under maximal therapeutic interventions including VA-ECMO [ 5 ]. Coronary malperfusion is the most common cause of PCCS [ 5 ].…”

“…Mortality rates are still high even under maximal therapeutic interventions including VA-ECMO [ 5 ]. Coronary malperfusion is the most common cause of PCCS [ 5 ]. Our institution’s management strategy for patients with PCCS due to coronary malperfusion is early revascularization and temporary MCS with VA-ECMO.…”

“…However, more extended VA-ECMO support does not provide any survival advantage. Therefore, we consider that the time on VA-ECMO should be limited in patients in whom weaning off seems to be unlikely [ 5 ]. An escalation of mechanical circulatory support should be considered in the patient subset where weaning of VA-ECMO is futile and no contraindications for definitive mechanical circulatory support exist.…”

Central versus Peripheral Postcardiotomy Veno-Arterial Extracorporeal Membrane Oxygenation: Systematic Review and Individual Patient Data Meta-Analysis

“…In particular, we decided to consider for this IPD meta-analysis only studies reporting on pre-VA-ECMO arterial lactate. This decision was based on the recent knowledge of the prognostic significance of arterial lactate as a marker of systemic tissue hypoxia in these critically ill patients [2,3,[8][9][10].…”

“…We decided not to include pediatric patients because of the expected marked differences between the pediatric and adult cardiac surgery populations regarding patients' characteristics and heart diseases. The decision to include only studies reporting on arterial lactate at the time of implantation of VA-ECMO was based on the significant prognostic impact of this biomarker of systemic tissue hypoxia on the early outcome of these critically ill patients [2,3,[8][9][10]. The population, intervention, comparison, and outcomes of the present study are summarized in Table 1.…”