Adult: Mechanical Circulatory Support
The importance of timing in postcardiotomy venoarterial extracorporeal membrane oxygenation: A descriptive multicenter observational study

Read at the 36th EACTS Annual Meeting, Milan, Italy, October 5-8, 2022, and at the EuroELSO Congress, Lisbon, Portugal, April 26-29, 2023.
https://doi.org/10.1016/j.jtcvs.2023.04.042Get rights and content
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Abstract

Objectives

Postcardiotomy extracorporeal membrane oxygenation (ECMO) can be initiated intraoperatively or postoperatively based on indications, settings, patient profile, and conditions. The topic of implantation timing only recently gained attention from the clinical community. We compare patient characteristics as well as in-hospital and long-term survival between intraoperative and postoperative ECMO.

Methods

The retrospective, multicenter, observational Postcardiotomy Extracorporeal Life Support (PELS-1) study includes adults who required ECMO due to postcardiotomy shock between 2000 and 2020. We compared patients who received ECMO in the operating theater (intraoperative) with those in the intensive care unit (postoperative) on in-hospital and postdischarge outcomes.

Results

We studied 2003 patients (women: 41.1%; median age: 65 years; interquartile range [IQR], 55.0-72.0). Intraoperative ECMO patients (n = 1287) compared with postoperative ECMO patients (n = 716) had worse preoperative risk profiles. Cardiogenic shock (45.3%), right ventricular failure (15.9%), and cardiac arrest (14.3%) were the main indications for postoperative ECMO initiation, with cannulation occurring after (median) 1 day (IQR, 1-3 days). Compared with intraoperative application, patients who received postoperative ECMO showed more complications, cardiac reoperations (intraoperative: 19.7%; postoperative: 24.8%, P = .011), percutaneous coronary interventions (intraoperative: 1.8%; postoperative: 3.6%, P = .026), and had greater in-hospital mortality (intraoperative: 57.5%; postoperative: 64.5%, P = .002). Among hospital survivors, ECMO duration was shorter after intraoperative ECMO (median, 104; IQR, 67.8-164.2 hours) compared with postoperative ECMO (median, 139.7; IQR, 95.8-192 hours, P < .001), whereas postdischarge long-term survival was similar between the 2 groups (P = .86).

Conclusions

Intraoperative and postoperative ECMO implantations are associated with different patient characteristics and outcomes, with greater complications and in-hospital mortality after postoperative ECMO. Strategies to identify the optimal location and timing of postcardiotomy ECMO in relation to specific patient characteristics are warranted to optimize in-hospital outcomes.

Key Words

mechanical circulatory support
extracorporeal membrane oxygenation
extracorporeal life support
postcardiotomy cardiogenic shock
cardiac surgery
acute heart failure

Abbreviations and Acronyms

CPB
cardiopulmonary bypass
ECMO
extracorporeal membrane oxygenation
ICU
intensive care unit
IQR
interquartile range
IRB
institutional review board
MCS
mechanical circulatory support
PELS-1
Postcardiotomy Extracorporeal Life Support Study
VA
venoarterial

Cited by (0)

Complete affiliations and list of all PELS-1 Investigators are included in Appendix E1.