Complications in Patients with Acute Myocardial Infarction Supported with Extracorporeal Membrane Oxygenation

Abstract

Background: There are limited data on complications in acute myocardial infarction (AMI) admissions receiving extracorporeal membrane oxygenation (ECMO). Methods: Adult (>18 years) admissions with AMI receiving ECMO support were identified from the National Inpatient Sample database between 2000 and 2016. Complications were classified as vascular, lower limb amputation, hematologic, and neurologic. Outcomes of interest included temporal trends, in-hospital mortality, hospitalization costs, and length of stay. Results: In this 17-year period, in~10 million AMI admissions, ECMO support was used in 4608 admissions (<0.01%)-mean age 59.5 ± 11.0 years, 75.7% men, 58.9% white race. Median time to ECMO placement was 1 (interquartile range [IQR] 0-3) day. Complications were noted in 2571 (55.8%) admissions-vascular 6.1%, lower limb amputations 1.1%, hematologic 49.3%, and neurologic 9.9%. There was a steady increase in overall complications during the study period (21.1% in 2000 vs. 70.5% in 2016). The cohort with complications, compared to those without complications, had comparable adjusted in-hospital mortality (60.7% vs. 54.0%; adjusted odds ratio 0.89 [95% confidence interval 0.77-1.02]; p = 0.10) but longer median hospital stay (12 [IQR 5-24] vs. 7 [IQR 3-21] days), higher median hospitalization costs ($458,954 [IQR 260,871] vs. 302,255 [IQR 173,660]), fewer discharges to home (14.7% vs. 17.9%), and higher discharges to skilled nursing facilities (44.1% vs. 33.9%) (all p < 0.001). Conclusions: Over half of all AMI admissions receiving ECMO support develop one or more severe complications. Complications were associated with higher resource utilization during and after the index hospitalization.

Same-Day Versus Non-Simultaneous Extracorporeal Membrane Oxygenation Support for In-Hospital Cardiac Arrest Complicating Acute Myocardial Infarction

“…ECMO support was identified (ICD-9CM 39.65; ICD-10CM 5A15223) consistent with prior literature [6,9,10]. Deyo's modification of the Charlson Comorbidity Index was used to identify comorbid diseases, and prior methodology was used to identify cardiac and non-cardiac procedures (Table S1) [1,2,6,9,15]. Similar to prior work from the HCUP-NIS, the timing of IHCA and ECMO were calculated using the day of the procedure, and simultaneous ECMO insertion was defined as that performed on the same hospital day as the IHCA [1,2,9,10,17,18].…”

“…Prior studies have shown administrative codes to have a high sensitivity and specificity for identification of IHCA [1,2,15,16]. ECMO support was identified (ICD-9CM 39.65; ICD-10CM 5A15223) consistent with prior literature [6,9,10]. Deyo's modification of the Charlson Comorbidity Index was used to identify comorbid diseases, and prior methodology was used to identify cardiac and non-cardiac procedures (Table S1) [1,2,6,9,15].…”

“…During the period between 1 January 2000 and 31 December 2017, a retrospective cohort of admissions from the HCUP-NIS with a primary diagnosis of AMI (International Classification of Disease-9 Clinical Modification (ICD-9CM) 410.x; International Classification of Disease-10 Clinical Modification (ICD-10CM) I21.x-22.x) with concomitant IHCA (ICD-9CM 99.60, 99.63, ICD-10PCS 5A12012) was identified [1,2,6,9,15]. Prior studies have shown administrative codes to have a high sensitivity and specificity for identification of IHCA [1,2,15,16].…”

“…In recent times, the use of extracorporeal membrane oxygenation (ECMO) for supporting cardiac arrest has increased to support refractory cardiac arrest and cardiogenic shock in this population [3][4][5]. ECMO is capable of supporting cardiac and respiratory function and provides 3-5 L of cardiac output support as well as dual ventricular support [6][7][8][9][10][11][12]. ECMO cannulation may be performed simultaneously with cardiopulmonary resuscitation (eCPR) or subsequently for ongoing ischemia or refractory cardiogenic shock [5].…”

Complications from percutaneous-left ventricular assist devices versus intra-aortic balloon pump in acute myocardial infarction-cardiogenic shock

“…However, since the HCUP-NIS database does not track patients across hospital admissions, this hypothesis will need additional studies for confirmation. We have previously shown that complications are associated with higher in-hospital resource utilization and therefore judicious patient selection is key to employ these devices [36].…”