Mortality and cost of post-cardiotomy extracorporeal support in the United States

Abstract

Background Extracorporeal membrane oxygenation (ECMO) has been used increasingly for cardiopulmonary rescue. Despite recent advances however, post-cardiotomy shock (PCS)-ECMO survival remains comparatively poor. We sought to evaluate outcomes and define factors that predict in-hospital mortality. Methods We used the Nationwide Inpatient Sample (NIS) to evaluate adult hospitalizations with a primary procedure code for coronary artery bypass grafting (CABG), and/or valve procedures performed between 2013 and 2018, which also required post cardiotomy ECMO support. Patient-related factors and hospital costs were evaluated to identify those associated with in-hospital mortality. Results There were 1,247,835 admissions for cardiac surgical procedures during the study period. Post-cardiotomy shock-ECMO support was provided in 4475 (0.3%) within the study cohort. A total of 2000 (44.7%) hospitalizations involved isolated valvular procedures, 1700 (38.0%) isolated CABG, and 775 (17.3%) involved a combination of both. Overall, in-hospital mortality was 42.1% ( n = 1880). Factors significantly associated with in-hospital mortality included patients with multiple comorbidities (> 7) and those undergoing combination of valve and CABG procedures. Only 26.6% of those who survived to discharge, were discharged home independently. Conclusion Survival to independent home discharge is rare following PCS-ECMO. Its high mortality is associated with multiple comorbidities and combination of CABG and valve surgery.

Health Disparities in Extracorporeal Membrane Oxygenation Utilization and Outcomes: A Scoping Review and Methodologic Critique of the Literature*

“…Of six adult ECMO studies investigating mortality, five observed patients (83%) with higher SES measured by ZIP code median income or Medicare wage index had improved survival (88, 103, 122–124). Three showed no association with other outcomes (complications or readmissions) (56, 65, 125, 126). One study incorporating all ages (127) and four pediatric studies found no association between SES and outcomes (31, 77, 86, 107).…”

“…Eight studies reported improved survival in patients with private relative to government insurance (28, 77, 88, 89, 106, 123, 128, 129). Eight found no survival difference (55, 65, 81, 92, 130–133), with variable cost, complication, readmission, and LOS results (31, 33, 56, 70, 125, 126, 128, 134), including one with higher renal replacement in privately insured patients (83).…”

“…Categories delineating race or ethnicity varied markedly. Overall, 54 studies (58%) found no statistical association between race and/or ethnicity and outcome (37–76), while 36 (39%) observed adverse outcomes in populations from underrepresented/diverse racial or ethnic backgrounds (Black/African American, Asian, Hispanic, or “other”/“non-Caucasian”/“non-White”). Of citations identifying adverse outcomes, 8 (22%) used univariate (77–84) and 28 (78%) used multivariate analyses.…”

Heterogeneity in clinical practices for post‐cardiotomy extracorporeal life support: A pilot survey from the PELS‐1 multicenter study

“…Post‐cardiotomy cardiogenic shock represents one of the most common ECLS indications in adults 2,3,4,5,14 . The current clinical scenario pushes every cardiac surgery unit to provide an ECLS service besides the normal cardiac surgery activity, regardless of the center's ECLS case load.…”

“…Post-cardiotomy cardiogenic shock represents one of the most common ECLS indications in adults. 2,3,4,5,14 The current clinical scenario pushes every cardiac surgery unit to provide an ECLS service besides the normal cardiac surgery activity, regardless of the center's ECLS case load. Nevertheless, to optimize outcomes, it is recommended that centers performing ECLS for cardiac failure achieve a minimum ECLS volume of 30 cases per year, with a substantial proportion being for cardiac failure.…”