Structured review of post-cardiotomy extracorporeal membrane oxygenation: part 1—Adult patients

Lorusso, Roberto; Raffa, Giuseppe Maria; Alenizy, Khalid; Sluijpers, Niels; Makhoul, Maged; Brodie, Daniel; McMullan, M.; Wang, I-Wen; Meani, Paolo; MacLaren, Graeme; Kowalewski, Mariusz; Dalton, Heidi J.; Barbaro, Ryan P.; Hou, Xiaotong; Cavarocchi, Nicholas C.; Chen, Yih‐Sharng; Thiagarajan, Ravi R.; Alexander, Peta; Alsoufi, Bahaaldin; Bermúdez, C.; Shah, Ashish S.; Haft, Jonathan W.; D’Alessandro, David A.; Boeken, Udo; Whitman, Glenn

doi:10.1016/j.healun.2019.08.014

Cited by 86 publications

(82 citation statements)

References 92 publications

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“…We found that, regardless the strategy (IABP, Impella, others) and the etiology (PCS [59][60][61], AMI, other), LV unloading has a positive impact in patients' weaning, without adding any further risk of CVE, sepsis, acute renal injury requiring dialysis, limb complications and reoperation for bleeding. We have also provided a separate analysis of propensity-score matched and adjusted studies, trying, in the absence of prospective randomized data, to address the high heterogeneity of the included experiences due to different baseline populations' characteristics.…”

Section: Limitationsmentioning

confidence: 81%

Left Ventricle Unloading with Veno-Arterial Extracorporeal Membrane Oxygenation for Cardiogenic Shock. Systematic Review and Meta-Analysis

Kowalewski

Malvindi

Zieliński³

et al. 2020

JCM

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During veno-arterial extracorporeal membrane oxygenation (VA-ECMO), the increase of left ventricular (LV) afterload can potentially increase the LV stress, exacerbate myocardial ischemia and delay recovery from cardiogenic shock (CS). Several strategies of LV unloading have been proposed. Systematic review and meta-analysis in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement included adult patients from studies published between January 2000 and March 2019. The search was conducted through numerous databases. Overall, from 62 papers, 7581 patients were included, among whom 3337 (44.0%) received LV unloading concomitant to VA-ECMO. Overall, in-hospital mortality was 58.9% (4466/7581). A concomitant strategy of LV unloading as compared to ECMO alone was associated with 12% lower mortality risk (RR 0.88; 95% CI 0.82-0.93; p < 0.0001; I 2 = 40%) and 35% higher probability of weaning from ECMO (RR 1.35; 95% CI 1.21-1.51; p < 0.00001; I 2 = 38%). In an analysis stratified by setting, the highest mortality risk benefit was observed in case of acute myocardial infarction: RR 0.75; 95%CI 0.68-0.83; p < 0.0001; I 2 = 0%. There were no apparent differences between two techniques in terms of complications. In heterogeneous populations of critically ill adults in CS and supported with Abstract Structured summary 2Provide a structured summary including, as applicable: background; objectives; data sources; study eligibility criteria, participants and interventions; study appraisal and synthesis methods; results; limitations; conclusions and implications of key findings; systematic review registration number.

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Section: Limitationsmentioning

confidence: 81%

Left Ventricle Unloading with Veno-Arterial Extracorporeal Membrane Oxygenation for Cardiogenic Shock. Systematic Review and Meta-Analysis

Kowalewski

Malvindi

Zieliński³

et al. 2020

JCM

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“…Despite the release in 2014 of ELSO anticoagulation guidelines with the aim to standardize the ECMO management, remarkable heterogeneity still persists among ECMO centres and no major advance has been observed in the prevention or reduction of bleeding complications [15,56]. Since heparin represents the usual first-line anticoagulant, commonly, post-cardiotomy V-A ECMO is associated with a high rate of bleeding events and changes in the coagulation cascade [57,58]. However, other anticoagulants have been shown less haemorrhagic complications than heparin.…”

Section: Discussionmentioning

confidence: 99%

Platelets and extra-corporeal membrane oxygenation in adult patients: a systematic review and meta-analysis

et al. 2020

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Despite increasing improvement in extracorporeal membrane oxygenation (ECMO) technology and knowledge, thrombocytopenia and impaired platelet function are usual findings in ECMO patients and the underlying mechanisms are only partially elucidated. The purpose of this meta-analysis and systematic review was to thoroughly summarize and discuss the existing knowledge of platelet profile in adult ECMO population. All studies meeting the inclusion criteria (detailed data about platelet count and function) were selected, after screening literature from July 1975 to August 2019. Twenty-one studies from 1.742 abstracts were selected. The pooled prevalence of thrombocytopenia in ECMO patients was 21% (95% CI 12.9-29.0; 14 studies). Thrombocytopenia prevalence was 25.4% (95% CI 10.6-61.4; 4 studies) in veno-venous ECMO, whereas it was 23.2% (95% CI 11.8-34.5; 6 studies) in veno-arterial ECMO. Heparin-induced thrombocytopenia prevalence was 3.7% (95% CI 1.8-5.5; 12 studies). Meta-regression revealed no significant association between ECMO duration and thrombocytopenia. Platelet function impairment was described in 7 studies. Impaired aggregation was shown in 5 studies, whereas loss of platelet receptors was found in one trial, and platelet activation was described in 2 studies. Platelet transfusions were needed in up to 50% of the patients. Red blood cell transfusions were administered from 46 to 100% of the ECMO patients. Bleeding events varied from 16.6 to 50.7%, although the cause and type of haemorrhage was not consistently reported. Thrombocytopenia and platelet dysfunction are common in ECMO patients, regardless the type of ECMO mode. The underlying mechanisms are multifactorial, and understanding and management are still limited. Further research to design appropriate strategies and protocols for its monitoring, management, or prevention should be matter of thorough investigations.

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“…Recovery of adequate cardiac and respiratory function is a pre-requisite. Some authors suggest weaning as early as 48–72 h [ 22 ] but rarely beyond 15 days, except in cases of post-heart transplantation for resolution of pulmonary hypertension [ 4 ]. Recovery of cardiac function in the post-cardiotomy setting is limited and rare beyond 7 days [ 15 , 23 ].…”

Section: Post-cardiotomy Va-ecmomentioning

confidence: 99%

“…VA-ECMO facilitates luxurious end-organ perfusion and adequate gas exchange and supports organ functionality allowing time for recovery/ bridge to decision. However, its usage has not been directly linked with early positive outcomes with few articles reporting increased mortality [ 4 – 6 ]. Post-cardiotomy VA-ECMO is used in both adult and paediatric populations [ 4 ].…”

Section: Introductionmentioning

confidence: 99%

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Veno-arterial extracorporeal membrane oxygenation: Special reference for use in ‘post-cardiotomy cardiogenic shock’ — A review with an Indian perspective

Patangi

Shetty

Shanmugasundaram

et al. 2020

Indian J Thorac Cardiovasc Surg

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The ultimate goals of cardiovascular physiology are to ensure adequate end-organ perfusion to satisfy the local metabolic demand, to maintain homeostasis and achieve ‘milieu intérieur’. Cardiogenic shock is a state of pump failure which results in tissue hypoperfusion and its associated complications. There are a wide variety of causes which lead to this deranged physiology, and one such important and common scenario is the post-cardiotomy state which is encountered in cardiac surgical units. Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is an important modality of managing post-cardiotomy cardiogenic shock with variable outcomes which would otherwise be universally fatal. VA-ECMO is considered as a double-edged sword with the advantages of luxurious perfusion while providing an avenue for the failing heart to recover, but with the problems of anticoagulation, inflammatory and adverse systemic effects. Optimal outcomes after VA-ECMO are heavily reliant on a multitude of factors and require a multi-disciplinary team to handle them. This article aims to provide an insight into the pathophysiology of VA-ECMO, cannulation techniques, commonly encountered problems, monitoring, weaning strategies and ethical considerations along with a literature review of current evidence-based practices.

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Structured review of post-cardiotomy extracorporeal membrane oxygenation: part 1—Adult patients

Cited by 86 publications

References 92 publications

Left Ventricle Unloading with Veno-Arterial Extracorporeal Membrane Oxygenation for Cardiogenic Shock. Systematic Review and Meta-Analysis

Left Ventricle Unloading with Veno-Arterial Extracorporeal Membrane Oxygenation for Cardiogenic Shock. Systematic Review and Meta-Analysis

Platelets and extra-corporeal membrane oxygenation in adult patients: a systematic review and meta-analysis

Veno-arterial extracorporeal membrane oxygenation: Special reference for use in ‘post-cardiotomy cardiogenic shock’ — A review with an Indian perspective

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