Venoarterial extracorporeal membrane oxygenation for postcardiotomy cardiogenic shock—A six‐year service evaluation

Abstract

Only a small number of English hospitals provide postcardiotomy venoarterial extracorporeal membrane oxygenation (VA‐ECMO) and there are doubts about its efficacy and safety. The aim of this service evaluation was to determine local survival rates and report on patient demographics. This was a retrospective service evaluation of prospectively recorded routine clinical data from a tertiary cardiothoracic center in the United Kingdom offering services including cardiac and thoracic surgery, heart and lung transplantation, venovenous extracorporeal membrane oxygenation (VV‐ECMO) for respiratory failure, and all types of mechanical circulatory support. In six years, 39 patients were supported with VA‐ECMO for refractory postcardiotomy cardiogenic shock (PCCS). We analyzed survival data and looked for associations between survival rates and patient characteristics. The intervention was venoarterial‐ECMO in patients with PCCS either following weaning from cardiopulmonary bypass or following a trial of inotropes and intra‐aortic balloon counterpulsation on the intensive care unit. 30‐day, hospital discharge, 1‐year and 2‐year survivals were 51.3%, 41%, 37.5%, and 38.5%, respectively. The median (IQR [range]) duration of support was 6 (4‐9 [1‐35]) days. Nonsurvival was associated with advanced age, shorter intensive care length of stay, and the requirement for postoperative hemofiltration. Reasonable survival rates can be achieved in selected patients who may have been expected to have a worse mortality without VA‐ECMO. We suggest postoperative VA‐ECMO should be available to all patients undergoing cardiac surgery be it in their own center or through an established pathway to a specialist center.

Outcomes and factors associated with early mortality in pediatric postcardiotomy veno‐arterial extracorporeal membrane oxygenation

“…All patients in this cohort were postcardiotomy pediatric patients with VA‐ECMO support. The overall survival rate was 47.1%, consistent with previous researches 1‐4 …”

“…Although medical management and equipment have greatly improved, mortality of children with congenital heart disease (CHD) who receive postcardiotomy VA‐ECMO support remains high. The survival rates vary from 1/3 to 2/3 in different hospitals 1‐4 . Diverse complications during ECMO, such as bleeding and thrombosis, 5 acute kidney injury (AKI), 6 and nosocomial infection 7 are linked with significant adverse effects on prognosis.…”

Venoarterial extracorporeal membrane oxygenation with intra-aortic balloon pump for postcardiotomy cardiogenic shock: A systematic review and meta-analysis

“…We reviewed the full-text of the remaining 70 publications and selected 10 studies meeting the inclusion criterion. [4][5][6][9][10][11][12][13][14][15] Characteristics of included studies are showed in Table 1. We included 2251 patients in the present study (917 patients in the VA-ECMO with IABP group and 1334 patients in the control group).…”

The challenges of venoarterial extracorporeal membrane oxygenation for postcardiotomy cardiogenic shock

“…For 39 patients receiving VA-ECMO for PCCS at our centre, the operations undertaken were coronary artery bypass grafts (CABG) (10.3%); aortic valve replacement +/− CABG (28.2%); mitral valve surgery +/− CABG (15.4%); double/triple valve surgery +/− CABG (20.5%); pericardectomy (5.1%); and thoracic aortic surgery (20%). The median (IQR [range]) ECMO run was 6 (4–9 [1–35]) days [ 25 ].…”

“…Unfortunately, the answer is not to simply perform a randomised controlled trial (RCT) [ 9 ]. This would invoke the unethical randomisation of patients to a non-VA-ECMO arm that will most likely lead to death as compared with a treatment that is arguably beyond experimental and where outcomes are reasonable [ 25 ]. Furthermore, we argue that to statistically treat VA-ECMO as a binary intervention with an on/off switch, such as a pharmaceutical agent, is a gross oversimplification.…”