Extracorporeal membrane oxygenation for refractory cardiogenic shock: patient survival and health-related quality of life

Background: The use of venoarterial extracorporeal membrane oxygenation in cardiogenic shock keeps increasing, but its cost-utility is unknown. Methods: We studied retrospectively the cost-utility of venoarterial extracorporeal membrane oxygenation in a five-year cohort of consequent patients treated due to refractory cardiogenic shock or cardiac arrest in a transplant centre in 2013–2017. In our centre, venoarterial extracorporeal membrane oxygenation is considered for all cardiogenic shock patients potentially eligible for heart transplantation, and for selected postcardiotomy patients. We assessed the costs of the index hospitalization and of the one-year hospital costs, and the patients’ health-related quality of life (response rate 71.7%). Based on the data and the population-based life expectancies, we calculated the amount and the costs of quality-adjusted life years gained both without discount and with an annual discount of 3.5%. Results: The cohort included 102 patients (78 cardiogenic shock; 24 cardiac arrest) of whom 67 (65.7%) survived to discharge and 66 (64.7%) to one year. The effective costs per one hospital survivor were 242,303€. Median in-hospital costs of the index hospitalization per patient were 129,967€ (interquartile range 150,340€). Mean predicted number of quality-adjusted life years gained by the treatment was 20.9 (standard deviation 9.7) without discount, and the median cost per quality-adjusted life year was 7474€ (interquartile range 10,973€). With the annual discount of 3.5%, 13.0 (standard deviation 4.8) quality-adjusted life years were gained with the cost of 12,642€ per quality-adjusted life year (interquartile range 15,059€). Conclusions: We found the use of venoarterial extracorporeal membrane oxygenation in refractory cardiogenic shock and cardiac arrest justified from the cost-utility point of view in a transplant centre setting.

show abstract

“…The VA ECMO criteria, VA ECMO circuits used and VA ECMO management protocol of our institute has been described in detail previously. 7…”

Section: Definition Of Cs and Patient Selection For Va Ecmomentioning

confidence: 99%

“…1,2 VA ECMO can be used to stabilise patients in CS to allow cardiac recovery, health-related quality of life ). 3 One-year survival rates after VA ECMO in cardiogenic shock are 25-65% [4][5][6][7] and in refractory CA 16-29%. [8][9][10] Treatment of acute heart failure and CS requires significant resources.…”

Section: Introductionmentioning

confidence: 99%

Cost-utility of venoarterial extracorporeal membrane oxygenation in cardiogenic shock and cardiac arrest

Jäämaa‐Holmberg

Salmela

Suojaranta

et al. 2020

European Heart Journal: Acute Cardiovascular Care

Self Cite

View full text Add to dashboard Cite

show abstract

“…Although no randomized controlled trials evaluated the effectiveness of VA-ECMO in cardiogenic shock, a meta-analysis of observational studies showed an association of VA-ECMO in cardiogenic shock with reduced 30 day mortality, 107 and early initiation (before the onset of MODS) was also related to favourable outcomes in patients with cardiogenic shock. 26,108 Currently, ongoing clinical trials are investigating the use of VA-ECMO in patients with cardiogenic shock (i.e. ECLS-SHOCK, NCT036372205, ANCHOR, NCT03813134, ECMO-CS, and NCT02301819).…”

Section: Mechanical Circulatory Supportmentioning

confidence: 99%

“…Venous–arterial extracorporeal membrane oxygenation (VA‐ECMO) is used to support cardiovascular and respiratory systems, which establishes a large amount of right‐to‐left shunt by draining venous blood from the right atrium and returning it after oxygenation to the ascending aorta (central cannulation) or the iliac artery (peripheral cannulation), and strongly improves end‐organ perfusion. Although no randomized controlled trials evaluated the effectiveness of VA‐ECMO in cardiogenic shock, a meta‐analysis of observational studies showed an association of VA‐ECMO in cardiogenic shock with reduced 30 day mortality, 107 and early initiation (before the onset of MODS) was also related to favourable outcomes in patients with cardiogenic shock 26,108 . Currently, ongoing clinical trials are investigating the use of VA‐ECMO in patients with cardiogenic shock (i.e.…”

Section: Tissue Hypoperfusionmentioning

confidence: 99%

Time‐sensitive approach in the management of acute heart failure

et al. 2020

View full text Add to dashboard Cite

Acute heart failure (AHF) has become a global public health burden largely because of the associated high morbidity, mortality, and cost. The treatment options for AHF have remained relatively unchanged over the past decades. Historically, clinical congestion alone has been considered the main target for treatment of acute decompensation in patients with AHF; however, this is an oversimplification of the complex pathophysiology. Within the similar clinical presentation of congestion, significant differences in pathophysiological mechanisms exist between the fluid accumulation and redistribution. Tissue hypoperfusion is another vital characteristic of AHF and should be promptly treated with appropriate interventions. In addition, recent clinical trials of novel therapeutic strategies have shown that heart failure management is 'time sensitive' and suggested that treatment selection based on individual aetiologies, triggers, and risk factor profiles could lead to better outcomes. In this review, we aim to describe the specifics of the 'time-sensitive' approach by the clinical phenotypes, for example, pulmonary/systemic congestion and tissue hypoperfusion, wherein patients are classified based on pathophysiological conditions. This mechanistic classification, in parallel with the comprehensive risk assessment, has become a cornerstone in the management of patients with AHF and thus supports effective decision making by clinicians. We will also highlight how therapeutic modalities should be individualized according to each clinical phenotype.

show abstract

“…Several studies included in this review have drawn associations between increased transfusions and poorer survival in ECMO patients [ 14 , 64 , 66 , 67 ] as well as in other ICU populations such as post cardiac surgery [ 68 ], while our work suggests higher transfusion rates in cohorts with below-median survival. The direction and strength of this association are uncertain, as the transfusion of any allogeneic blood product comes with well-recognised immunologic and nonimmunologic risks.…”

Section: Discussionmentioning

confidence: 61%

A Systematic Literature Review of Packed Red Cell Transfusion Usage in Adult Extracorporeal Membrane Oxygenation

et al. 2021

View full text Add to dashboard Cite

Background: Blood product administration plays a major role in the management of patients treated with extracorporeal membrane oxygenation (ECMO) and may be a contributor to morbidity and mortality. Methods: We performed a systematic review of the published literature to determine the current usage of packed red cell transfusions. Predefined search criteria were used to identify journal articles reporting transfusion practice in ECMO by interrogating EMBASE and Medline databases and following the PRISMA statement. Results: Out of 1579 abstracts screened, articles reporting ECMO usage in a minimum of 10 adult patients were included. Full texts of 331 articles were obtained, and 54 were included in the final analysis. All studies were observational (2 were designed prospectively, and two were multicentre). A total of 3808 patients were reported (range 10–517). Mean exposure to ECMO was 8.2 days (95% confidence interval (CI) 7.0–9.4). A median of 5.6% was not transfused (interquartile range (IQR) 0–11.3%, 19 studies). The mean red cell transfusion per ECMO run was 17.7 units (CI 14.2–21.2, from 52 studies) or 2.60 units per day (CI 1.93–3.27, from 49 studies). The median survival to discharge was 50.8% (IQR 40.0–64.9%). Conclusion: Current evidence on transfusion practice in ECMO is mainly drawn from single-centre observational trials and varies widely. The need for transfusions is highly variable. Confounding factors influencing transfusion practice need to be identified in prospective multicentre studies to mitigate potential harmful effects and generate hypotheses for interventional trials.

show abstract

Extracorporeal membrane oxygenation for refractory cardiogenic shock: patient survival and health-related quality of life

Cited by 15 publications

References 25 publications

Cost-utility of venoarterial extracorporeal membrane oxygenation in cardiogenic shock and cardiac arrest

Cost-utility of venoarterial extracorporeal membrane oxygenation in cardiogenic shock and cardiac arrest

Time‐sensitive approach in the management of acute heart failure

A Systematic Literature Review of Packed Red Cell Transfusion Usage in Adult Extracorporeal Membrane Oxygenation

Contact Info

Product

Resources

About