Veno‐Arterial Extracorporeal Membrane Oxygenation Support in Patients Undergoing Aortic Surgery

Abstract

Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is an option for mechanical support for patients with postcardiotomy cardiogenic shock (PCS). However, the use of VA-ECMO in patients suffering from aortic disease with PCS has not been greatly reported. This is a retrospective review of adult patients undergoing aortic surgery who received VA-ECMO support to treat refractory PCS from August 2009 to May 2016. A total of 36 patients who underwent aortic surgery with VA-ECMO support for refractory PCS were included. Preoperative, perioperative, and postoperative variables were assessed and analyzed for possible correlation with in-hospital mortality. After a mean duration of 3.6 ± 2.9 days, 24 patients (67%) were weaned off VA-ECMO, and 18 patients (50%) were discharged from the hospital. The overall in-hospital mortality was 50%. The main cause of death was multiple organ dysfunction. The survivors had a lower level of preoperative creatine kinase-MB (CK-MB), a higher rate of antegrade cannulation, and a lower lactate level at 12 h, respectively. Relevant factors for in-hospital mortality were retrograde-flow cannulation (odds ratio [OR], 2.49), peak lactate levels greater than 20 mmol/L (OR, 5.0), and preoperative CK-MB greater than 100 IU/L (OR, 6.40). Antegrade cannulation may provide better perfusion and should be emphasized to improve outcomes. Additionally, levels of peak serum lactate and preoperative CK-MB may be relevant factors for in-hospital mortality in aortic patients with PCS.

Outcomes after extracorporeal life support for postcardiotomy cardiogenic shock

“…authors concluded that ECLS implantation in acute aortic dissection is associated with extremely high mortality irrespective of when the intervention is performed. The mean duration of temporary mechanical support in our series was quite longer than that reported in previous studies [3][4][5][6][7][8][9][10][11][12][13][14][15][16][17][18][19][20]. Our analysis did not find a survival advantage in the most recent cohort.…”

“…24,25 In the present analysis, half of the study population showed signs of satisfactory myocardial recovery allowing for ECLS weaning but only 39% survived to hospital discharge. [3][4][5][6][7][8][9][10][11][12][13][14][15][16][17][18][19][20] In addition, a recent metaanalysis found that the pooled hospital survival after postcardiotomy ECLS was 36% (95% CI 31.5-40.8). [3][4][5][6][7][8][9][10][11][12][13][14][15][16][17][18][19][20] In addition, a recent metaanalysis found that the pooled hospital survival after postcardiotomy ECLS was 36% (95% CI 31.5-40.8).…”

“…The mean duration of temporary mechanical support in our series was quite longer than that reported in previous studies. [3][4][5][6][7][8][9][10][11][12][13][14][15][16][17][18][19][20] Distelmaier et al recently showed that ECLS support of more than 7 days negatively affects short-and long-term survival in 354 PCS patients. 19 Despite a longer period of mechanical support, the complication rate was quite comparable to previous studies in terms of surgical revision for bleeding, leg ischemia, and acute renal failure requiring renal replacement therapy.…”

“…This observation is in line with a recent position paper of the International Society for Adult Congenital Heart Disease stating that the prevalence of adults with congenital heart disease is steadily increasing over time in developed countries and currently outnumbers the prevalence of children with congenital heart disease 27. Aortic surgery was the leading open-heart procedure requiring temporary mechanical support with a stable incidence over time and better survival rate (46%) as compared to other types of cardiac interventions 18. Sultan et al described ECLS implementation in the setting of type A aortic dissection 28.…”

Concurrent Implantation of Intra‐Aortic Balloon Pump and Extracorporeal Membrane Oxygenation Improved Survival of Patients With Postcardiotomy Cardiogenic Shock

“…Extra corporeal membrane oxygenation (ECMO) as a short‐term mechanical circulatory support has been widely used in patients with severe respiratory and/or circulatory failure . However, the rate of ECMO removal in PCS remains one of the lowest rates of all the indications varying from 58 to 67%, and the in‐hospital mortality varies from 50 to 74% Although the survival rate of ECMO support remains unsatisfactory with severe complications, such as bleeding, infection, end‐organ failures, lower limb ischemia, and thrombosis, ECMO is still a favorable technique treatment for PCS because of its easy and rapid applicability.…”