Postcardiotomy shock extracorporeal membrane oxygenation: Peripheral or central?

Abstract

Postcardiotomy shock (PCS) is poorly defined in the literature, but is broadly understood to mean circulatory failure after cardiac surgery necessitating mechanical circulatory support and high-dose inotropes. PCS occurs in 0.5% to 1.5% of all cardiac surgeries and is important to better understand because it has an in-hospital mortality rate >50%. 1,2 In the past there were a limited number of ways to support a patient in such profound cardiogenic shock, but today there are multiple mechanical circulatory support devices available. These include extracorporeal membrane oxygenation (ECMO), and several distinct technologies that fall into the category of ventricular assist device (VAD). VADs can be further classified by whether they provide short-term or long-term support, and percutaneous versus open insertion. 2 ECMO has become the most widely used support system for PCS. 3 Relative ease of ECMO cannulation and ability to deploy ECMO quickly in an emergency likely contribute to widespread use. Over the past 2 decades there has been a large increase in use of ECMO for all underlying etiologies, and a fivefold increase in the use of ECMO specifically for PCS. Unfortunately, the increase in use has not been paralleled by improved survival for patients in whom it is used. 3,4 The percentage of PCS patients treated with ECMO who survive to hospital discharge varies on the basis of source, but ranges from approximately 30% to 60%. [4][5][6] Several retrospective analyses have attempted to identify patient-specific characteristics associated with mortality in PCS patients. 3,6,7 A variety of factors have been identified in at least 1 study including age older than 70 years, preoperative renal insufficiency, obesity, female sex, and type of cardiac surgery among others. 1,3,6 In a recent analysis patients in two 5-year time periods (2007( -2012( and 2013

Comparative Analysis of Therapeutic Strategies in Post-Cardiotomy Cardiogenic Shock: Insight into a High-Volume Cardiac Surgery Center

“…Post-cardiotomy shock (PCS) is a clinical condition that remains poorly defined in the literature but implies a state of circulatory failure after cardiac surgery, necessitating high dosages of vasoactive medication, inotropes, and occasionally, mechanical circulatory support (MCS) [1]. The incidence of PCS in adult patients undergoing elective cardiac surgery is 2% to 6%, and more severe stages of PCS are associated with in-hospital mortality rates up to 90% [2].…”

“…It often begins with damage to the myocardium during cardiac surgery, the use of cardiopulmonary bypass, or cardioplegic myocardial arrest [4]. Insufficient myocardial protection or residual valvular dysfunction severely aggravates the situation and increases myocardial stunning, myocardial ischemia, ischemia-reperfusion injury, and left and/or ventricular pressure and/or volume overload, causing LCOS [1][2][3]. Additionally, a cascade of events can be set off, including inflammatory responses, neurohormonal activation, and endothelial dysfunction.…”

“…LCOS, especially in combination with hypotension because of the loss of peripheral vascular resistance in patients with preexistent compromised autoregulation, leads to reduced end-organ perfusion, end-organ failure, and ultimately, death [3]. The management of PCCS consists firstly of treatment of the underlying cardiac dysfunction, alongside hemodynamic stabilization, and support of end-organ hypoperfusion and dysfunction by volume resuscitation and pharmacological therapy (inotropes and/or vasopressors) [1,2,4]. MCS provides additional hemodynamic support by providing additional (forward) flow with or without the unloading of the right and/or left ventricle, depending on the type and canulation of different types of MCS [4].…”

N-Terminal of the Prohormone Brain Natriuretic Peptide Predicts Postoperative Cardiogenic Shock Requiring Extracorporeal Membrane Oxygenation

“…PCS is poorly defined in the literature, but it is broadly understood to mean circulatory failure after cardiac surgery which is resistant to inotropic support and/or an intra-aortic balloon pump (IABP), and which requires mechanical circulatory support (MCS) such extracorporeal membrane oxygenation (ECMO). ECMO may improve a patient’s physiological state when in cardiogenic shock by stabilizing hemodynamics and tissue metabolism, allowing the necessary time for regeneration of the heart muscle [ 5 , 6 , 7 , 8 ]. The available literature has little information on postcardiotomy shock in patients undergoing heart valve surgery.…”

Central versus Peripheral Postcardiotomy Veno-Arterial Extracorporeal Membrane Oxygenation: Systematic Review and Individual Patient Data Meta-Analysis

“…However, the lack of data from randomized studies on these strategies does not allow an understanding of their potential benefits and harms in this critical setting. The optimal access site for arterial cannulation for VA-ECMO is one of the most controversial topics [4]. A meta-analysis by Mariscalco et al [5] showed that peripheral cannulation for postcardiotomy VA-ECMO was associated with decreased in-hospital mortality compared to central arterial cannulation.…”