In-hospital mortality and successful weaning from venoarterial extracorporeal membrane oxygenation: analysis of 5,263 patients using a national inpatient database in Japan

Abstract

BackgroundThe mortality rate of severely ill patients treated with venoarterial extracorporeal membrane oxygenation (VA-ECMO) remains unknown because of differences in patient background, clinical settings, and sample sizes between studies. We determined the in-hospital mortality of VA-ECMO patients and the proportion weaned from VA-ECMO using a national inpatient database in Japan.MethodsPatients aged ≥19 years who received VA-ECMO during hospitalization for cardiogenic shock, pulmonary embolism, hypothermia, poisoning, or trauma between 1 July 2010 and 31 March 2013 were identified, using The Japanese Diagnosis Procedure Combination national inpatient database.ResultsThe primary outcome was in-hospital mortality and the secondary outcome was the proportion weaned from VA-ECMO. A total of 5263 patients received VA-ECMO during the study period. The majority of patients had cardiogenic shock (n = 4,658). The number of patients weaned from VA-ECMO was 3389 (64.4 %) and in-hospital mortality after weaning from VA-ECMO was 1994 (37.9 %). In-hospital mortality without cardiac arrest in the cardiogenic shock group was significantly lower than that in patients with cardiac arrest (70.5 % vs. 77.1 %, p <0.001). In the multivariable logistic regression including multiple imputation, higher age and greater or smaller body mass index were significantly associated with in-hospital mortality, whereas hospital volume was not associated with such mortality.ConclusionsThe present nationwide study showed high mortality rates in patients who received VA-ECMO, and in particular in patients with cardiogenic shock and in patients with cardiac arrest. Weaning from VA-ECMO did not necessarily result in survival. Further studies are warranted to clarify risk-adjusted mortality of VA-ECMO using more detailed data on patient background.

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

“…Conversely, one could argue that deferral of transplantation represents a lost, often narrow, window of opportunity, particularly in the setting of a preexisting cardiomyopathy. In a nationwide Japanese registry, patients with an underlying cardiomyopathy had an in‐hospital mortality of 29.5% while on VA‐ECMO, but a 43.5% in‐hospital mortality after weaning, suggesting that survival to decannulation was not sufficient to guarantee successful discharge in this population . Indeed, the one recurring theme across ECMO studies and consistent with our findings is the need for advanced support, either VAD or transplant, in patients with an underlying cardiomyopathy .…”

ECMO in cardiac arrest and cardiogenic shock

“…24 and 48 h after PCI and IABPECMO: 48 ± 10%IABP: 32 ± 13%30 d-survival 67.0% ECMO vs. 33.0% IABP3/12 bleeding2/12 compartment syndromehemolysis with 21.0 ± 12.4 packed red blood cell transfusions per patientAso et al. [71]JapanRegisterno device comparisonall had VA-ECMO42.2% Ischemic heart disease (IHD), 34.8% Heart failure (HF), 13.7% Valvular heart disease (VHD), 4% Myocarditis (MYO), 4.1% Cardiomyopathy (CMP), 0.7% Takotsubo syndrome (TS), 0.3% Infectious endocarditis (IE)Patients who had cardiac arrest: All 47%, IHD 25.0%, HF 15.0%, VHD 2.7%, MYO 1.4%, CMP 2.5%, TS 0.3%, IE 0.06%4,65873.0% menAll 64.8 ± 13.7 years (mean, SD)Data not reported60.8% had IABP prior to or in parallel to VA-ECMOData not reportedSurvival to dischargeall patients 26.4%, IHD 20.9%, HF 32.2%, VHD 23.0%, MYO 43.0%, CMP 26.9%, TS 35.3%, IE 25.0%Data not reportedMuller et al. [72]FranceProspective observationalno device comparisonall had VA-ECMO100% acute myocardial infarction13.8% received VA-ECMO during CPR and 43.5% after CPR13879.7% men55 (46–63) years(median, IQR)10.1% before and 89.9% after PCI69.6% had IABP parallel to ECMO2.2% had Impella and ECMO11.6% were switched to central ECMO cannulation20 (15–25)%(median, IQR)Successful weaning 35.5%6-months survival 41.3%39.1% ECMO complications: 12.3% bleeding 10.9% leg ischemia 11.6% access site infection 3.6% hemolysis 11.6% overt pulmonary edema on ECMO

CPR  cardiopulmonary resuscitation, ECMO  extracorporeal membrane oxygenation, ECPR  extracorporeal CPR, IABP  intra-aortic balloon pump, IQR interquartile range, LVEF  left ventricular ejection fraction, NSTEMI  Non-ST-elevation myocardial infarction, pat .

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Weaning from veno-arterial extra-corporeal membrane oxygenation: which strategy to use?

“…No randomized controlled trials have compared VA ECMO to other mechanical support systems in patients with cardiogenic shock. However, several nonrandomized studies suggest that the early use of ECMO offers a survival advantage in such circumstances (1)(2)(3)(4)(5)(6)(7)(8)(9)(10)(11)(12).…”