Liver function predicts survival in patients undergoing extracorporeal membrane oxygenation following cardiovascular surgery

Roth, Christian; Schrutka, Lore; Binder, Christina; Kriechbaumer, Lukas; Gisslinger, Heinz; Lang, Irene M.; Maurer, Gerald; Koinig, Herbert; Steinlechner, Barbara; Niessner, Alexander; Distelmaier, Klaus; Goliasch, Georg

doi:10.1186/s13054-016-1242-4

Cited by 51 publications

(58 citation statements)

References 42 publications

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“…In this study hyperbilirubinemia is related to the liver dysfunction. Liver dysfunction is very common in patients with ECMO support due to the compromised hemodynamic condition caused by ECMO . When liver is injured by ischemia, the bilirubin uptake and bile secretion will be impaired resulting in hyperbilirubinemia .…”

Section: Discussionmentioning

confidence: 99%

“…Bilirubin as the end product of heme catabolism is metabolized and excreted by liver. Hemolysis and liver hypoperfusion caused by ECMO techniques, abnormal liver function induced by cardiac failure and cardiac surgery before ECMO support may result in hyperbilirubinemia during ECMO support. Bilirubin at a high level can induce apoptosis, inflammation, and oxidative stress, which may lead to neural impairment , thrombocytopenia , and respiratory failure .…”

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confidence: 99%

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Incidence, Risk Factors, and Outcomes of Hyperbilirubinemia in Adult Cardiac Patients Supported by Veno‐Arterial ECMO

et al. 2017

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The aims of this study were to evaluate the incidence, risk factors, and outcomes of hyperbilirubinemia in cardiac patients with veno-arterial (VA) ECMO. Data on 89 adult patients with cardiac diseases who received VA ECMO implantation in our hospital were retrospectively reviewed. All patients were divided into the following three groups: 24 in normal group (N, total bilirubin [TBIL] ≤3 mg/dL), 30 in high bilirubin group (HB, 6 mg/dL ≥ TBIL > 3 mg/dL), and 35 in severe high bilirubin group (SHB, TBIL > 6 mg/dL). lg(variables + 1) was performed for nonnormally distributed variables. The incidence of hyperbilirubinemia (>3 mg/dL) was 73%. In a multiple linear regression analysis, lg(peak TBIL + 1) was significantly associated with lg(peak AST + 1) (b-coefficient 0.188, P = 0.001), lg(peak pFHb + 1) (b-coefficient 0.201, P = 0.003), and basic TBIL (b-coefficient 0.006, P = 0.009). Repeated measurement analysis of variance revealed that the main effect for three groups in pFHb and lg(AST + 1) was significant at first 3 days during ECMO. The patients in SHB had low platelets during ECMO and low in-hospital survival rate. Hyperbilirubinemia remains common in patients with VA ECMO and is associated with low platelets and high in-hospital mortality. Hemolysis and liver dysfunction during ECMO and basic high bilirubin levels are risk factors of hyperbilirubinemia.

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Section: Discussionmentioning

confidence: 99%

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confidence: 99%

Incidence, Risk Factors, and Outcomes of Hyperbilirubinemia in Adult Cardiac Patients Supported by Veno‐Arterial ECMO

et al. 2017

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“…Besides the understanding of underlying mechanisms of CNS events during ECLS, monitoring and timely recognition of the adequacy of brain perfusion or the onset of maladaptive changes and cerebral injury, either perfusion or structurerelated, is paramount, but mostly lacking in ECLS patients. On-line information about appropriateness of anticoagulation state and presence and extent of coagulation disorder, brain perfusion and onset of cerebral tissue injury, as well as information about vascular structural and functional integrity, are all part of the complex puzzle which constitutes the ECLS/ patient interplay which is, at the moment, poorly defined and understood (12)(13)(14)(15)(16)(17)(18). As mentioned, it is likely that CNS event-related etiology is multifactorial, but we are still far from understanding why some patients develop such brain damages and some not.…”

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confidence: 99%

“…More emphasis is currently applied in the search for enhanced brain monitoring (14)(15)(16)(17)(18), and this includes also the elucidation of not only overt brain injury, but also the impact of ECLS on more subtle and important aspects accounting for the neurocognitive status, particularly in children (19)(20)(21).…”

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confidence: 99%

Extracorporeal life support and neurologic complications: still a long way to go

Lorusso

2017

J. Thorac. Dis.

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The actual impact of neurological complications on patient outcome during extracorporeal life support (ECLS) has emerged only since a few years (1,2) despite the use of such a temporary heart/lung support for more than four decades.The recent appraisal of the rather high incidence and ominous prognosis of these adverse events in ECLS patients have now alerted attending physicians and personnel upon continuous surveillance and early recognition. Nonetheless, it is increasingly evident that the mechanisms underlying the occurrence are not simply linked to embolization, bleeding, or low-flow related brain hypoxia (3-5) which were thought to represent the sole source of injury of the brain in ECLS patients.Following a study addressing the neurologic complications in the neonatal population (6), other two studies realized by analysing the Registry of the Extracorporeal Life Support Organization (ELSO), have recently investigated and clearly shown the entity of neurologic adverse events in veno-arterial (V-A) and veno-venous (V-V) ECLS configurations in adult patient populations (7,8). Incidence rates of brain injury were 15% in V-A and 7% in V-V patients, respectively, with an in-hospital survival of 10% in the first group, and 25% in the second, underlining the ominous prognosis once a neurological event occurs in the ECLS patients (7,8). These studies analyzed also the type of brain damage, according to the ELSO reporting system (embolism, hemorrhage, seizures, brain death) but also, more importantly, the trends of the overall CNS complications and of the single typerelated rates of such adverse events during a 20-year period whose assessment provided interesting findings (7,8).The difference of neurologic complication rates between V-A and V-V is not surprising. However, the two studies, as also highlighted by the comments provided by Pappalardo, Hirose, and Perico herewith enclosed (9-11), have provided several relevant clues for further interpretation and discussion. Interestingly, the incidence of CNS events in V-A ECLS patients steadily declined in the recent years, whereas no substantial change was observed in the V-V ECLS population (7,8). It is well-known that patients undergoing V-A ECLS, by definition and as also confirmed by the ELSO Registry data, are usually more prone to experience bleeding and hemodynamic instability after ECLS implant than V-V cases, therefore at higher risk also for brain injury. This is due to either the underlying disease, settings, and clinical conditions of the ECLS candidates or to the ECLS access (arterial cannulation certainly at higher risk of bleeding than venous access). V-A ECLS, indeed, is often applied nowadays in patients suffering from cardiac arrest, condition which is directly linked to brain hypoperfusion

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“…Traditionally, the hepatic failure during ECLS was considered more a witness than an active element in determining a worse prognosis (16). Recently, Roth et al demonstrated that, in patients undergoing VA-ECMO following cardiovascular surgery, liver function tests (pre-ECMO alkaline phosphatase and total bilirubin) were strong predictors of short-and longterm mortality (17).…”

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confidence: 99%

Is there light at the end of the tunnel?—new perspectives in ECMO survival

Pappalardo¹,

Montisci

2016

J. Thorac. Dis.

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Cardiogenic shock (CS) is a state of systemic hypoperfusion, secondary to a deficit in cardiac contractile activity. Acute myocardial infarction (AMI) accounts for the majority of cases of CS, with a high mortality rate, despite the great improvements in revascularisation therapy. Nowadays, mechanical circulatory support (MCS) in CS often represents the only therapeutic approach able to restore systemic perfusion, determining a survival benefit. Recently, many efforts have been made to identify factors associated with mortality in patients receiving MCS devices. New insights into the pathophysiology of CS prompted the concept that the use of MCS should be considered early in the course of the disease, before the progression to multiorgan dysfunction. However, many questions remain unsolved and randomised trials in this field are hard to perform. Looking at the future, the timely implantation of temporary MCS, the correct selection of patient, the concomitant use of different temporary devices, the improvement in weaning strategies and the increasing use of durable devices as a destination or bridge therapy appear to be the most promising areas of development.

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Liver function predicts survival in patients undergoing extracorporeal membrane oxygenation following cardiovascular surgery

Cited by 51 publications

References 42 publications

Incidence, Risk Factors, and Outcomes of Hyperbilirubinemia in Adult Cardiac Patients Supported by Veno‐Arterial ECMO

Incidence, Risk Factors, and Outcomes of Hyperbilirubinemia in Adult Cardiac Patients Supported by Veno‐Arterial ECMO

Extracorporeal life support and neurologic complications: still a long way to go

Is there light at the end of the tunnel?—new perspectives in ECMO survival

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