Duration of veno-arterial extracorporeal life support (VA ECMO) and outcome: an analysis of the Extracorporeal Life Support Organization (ELSO) registry

Abstract

BackgroundVeno-arterial extracorporeal membrane oxygenation (VA ECMO) is an effective rescue therapy for severe cardiorespiratory failure, but morbidity and mortality are high. We hypothesised that survival decreases with longer VA ECMO treatment. We examined the Extracorporeal Life Support Organization (ELSO) registry for a relationship between VA ECMO duration and in-hospital mortality, and covariates including indication for support.MethodsAll VA runs from the ELSO database from 2002 to 2012 were extracted. Multiple runs and non-VA runs were excluded. Runs were categorized into diagnostic groups. Logistic regression for analysis of the effect of duration on outcome, and multivariate regression for diagnosis and other baseline factors were performed. Non-linear models including piecewise logistic models were fitted.ResultsThere were 2699 runs analysed over 14,747 days. Logistic regression analysis of the effect of duration on outcome, and multivariate regression analysis of diagnosis and other baseline factors were performed. In-hospital survival was 41.4% (95% CI 39.6–43.3). 75% of patients were supported for less than 1 week and 96% for less than 3 weeks. Median duration (4 days IQR 2.0–6.8) was greater in survivors (4.1 (IQR 2.5–6.7) vs 3.8 (IQR 1.7–7.0) p = 0.002). The final multivariate model demonstrated increasing survival to day 4 (OR 1.53 (95% CI 1.37–1.71) p < 0.001), decreasing from day 4 to 12 (OR 0.86 (95% CI 0.81–0.91), p < 0.001) with no significant change thereafter (OR 0.98 (95% CI 0.94–1.02), p = 0.400).ConclusionsECMO for 4 days or less is associated with higher mortality, likely reflecting early treatment failure. Survival is highest when patients are weaned on the fourth day of ECMO but likely decreases into the second week. While this does not suggest weaning at this point will produce better outcomes, it does reflect the likely time course of ECMO as a bridge in severe shock. Patients with some underlying conditions (like myocarditis and heart transplantation) achieve better outcomes despite longer support duration. These findings merit prospective study for the development of prognostic models and weaning strategies.

Extracorporeal cardiopulmonary resuscitation in children after open heart surgery

“…An Extracorporeal Life Support Organization (ELSO) data analysis indicated that the best survival was observed with venoarterial ECMO weaning at support day 4. A shorter duration was associated with higher mortality, most likely because of inadequate support, and a gradually decreasing survival from 4 to 12 days of assistance was also observed with a constant low survival beyond the second week of cardiorespiratory support.…”

VA‐ECMO for cardiogenic shock in the contemporary era of heart transplantation: Which patients should be urgently transplanted?

“…The number of VA‐ECMO cases has increased fourfold between 2010 and 2015 establishing its central role in the management of cardiogenic shock . However, outcomes remain poor with a 41% survival to discharge and no clear trend toward improvement . In an effort to reduce waitlist mortality, the new UNOS organ allocation policy has given patients supported on VA‐ECMO Tier 1 (highest priority) status and is therefore likely to render urgent HT from VA‐ECMO as a feasible option at centers where long wait times previously precluded this approach.…”

“…Venoarterial extracorporeal membrane oxygenation (VA‐ECMO) provides temporary circulatory support for patients in refractory cardiogenic shock. While its use has increased exponentially over the past decade, outcomes have not followed the same trajectory . Heart transplant (HT) from VA‐ECMO is a feasible option as demonstrated in the pediatric population and in countries where these patients are given high priority status .…”

Invasive pulmonary aspergillosis is associated with adverse clinical outcomes in critically ill patients receiving veno-venous extracorporeal membrane oxygenation

“…Its use is increasing but survival to hospital discharge remains between 50 and 60% [2]. Older age, being immunocompromised, longer duration of mechanical ventilation before vv-ECMO, neuromuscular blockade agents, nitric oxide use and increased extra-pulmonary organ failure are associated with worse outcomes [3–5].…”