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

doi:10.1016/j.healun.2019.08.014

The Journal of Heart and Lung Transplantation

Volume 38, Issue 11, November 2019, Pages 1125-1143

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https://doi.org/10.1016/j.healun.2019.08.014 Get rights and content

Cardiogenic shock, cardiac arrest, acute respiratory failure, or a combination of such events, are all potential complications after cardiac surgery which lead to high mortality. Use of extracorporeal temporary cardio-circulatory and respiratory support for progressive clinical deterioration can facilitate bridging the patient to recovery or to more durable support. Over the last decade, extracorporeal membrane oxygenation (ECMO) has emerged as the preferred temporary artificial support system in such circumstances. Many factors have contributed to widespread ECMO use, including the relative ease of implantation, effectiveness, versatility, low cost relative to alternative devices, and potential for full, not just partial circulatory support. While there have been numerous publications detailing the short and midterm outcomes of ECMO support, specific reports about post-cardiotomy ECMO (PC-ECMO), are limited, single-center experiences. Etiology of cardiorespiratory failure leading to ECMO implantation, associated ECMO complications, and overall patient outcomes may be unique to the PC-ECMO population. Despite the rise in PC-ECMO use over the past decade, short-term survival has not improved.

This report, therefore, aims to present a comprehensive overview of the literature with respect to the prevalence of ECMO use, patient characteristics, ECMO management, and in-hospital and early post-discharge patient outcomes for those treated for post-cardiotomy heart, lung, or heart-lung failure.

Section snippets

Trends in use

The incidence of ECMO implementation in patients after open-heart surgery has been reported between 0.4% and 3.7% (Table 1). PC-ECMO has increased considerably over the past 2 decades.² Indeed, from 2007 to 2011, non-percutaneous ECMO cannulation increased 2-fold, while the use of percutaneous ECMO increased by more than 15-fold.² Maxwell and colleagues, evaluating more than 9,000 ECMO patients from the Nationwide Inpatient Sample database in the United States from 1998 to 2009, identified

Cannulation

The location of ECMO cannulation is influenced by the timing and indication, urgency of deployment, cardio-circulatory versus respiratory support required, and institutional factors including staff familiarity and availability of ECMO circuits. PC-ECMO is most often utilized for failure to wean from CPB, so operating room cannulation occurs most frequently, followed by the ICU, and rarely on the ward (Table 2). While PC-ECMO can be initiated any time in the postoperative course, the majority of

Weaning from PC-ECMO and survival to hospital discharge

As expected, successful weaning from PC-ECMO varies greatly within published series, ranging from 31% to 76%, with almost half of the published experiences showing a weaning rate at or slightly above 50% (Table 4). Survival to hospital discharge rates are far less, ranging from 16% to 52%, with fewer than 30% of the centers reporting survival-to-discharge above 40% (Table 4). Of note, even in the face of considerably improved technology and increased experience in managing ECMO care, survival

Post-cardiotomy veno-venous ECMO for respiratory dysfunction

Respiratory insufficiency is a common complication after cardiac surgery and an independent predictor of in-hospital mortality.97, 98 Despite respiratory complications in 7% to 30% of patients,97, 98 there is a paucity of published reports on ECMO therapy when this complication is severe, treated either with VA- or veno-venous ECMO (VV-ECMO). VV-ECMO has been increasingly employed as therapy for primary, refractory respiratory failure as a result of the outcomes seen in conventional ventilatory

Controversial issues and future perspectives on PC-ECMO

ECMO technology has undergone remarkable progress in the last 20 years. More advanced, user-friendly, miniaturized technology has rendered the wider application of this temporary support possible, in many instances for conditions once viewed as contraindications.12, 101 Obvious targets to improve effectiveness include biocompatible circuitry (e.g., the pump, oxygenator, and tubing design), more reliable anticoagulation, rational vasoactive or inotropic support, a better understanding of the

Limitations of the review

This review has some limitations, as it encompasses different patient conditions and different ECMO approaches in its attempt to be comprehensive. However, underlying cardiopulmonary insufficiency and a lack of response to conservative, conventional treatments after cardiac surgery are common to all the studies included. The scenarios for PC-ECMO include conditions ranging from failure to wean from CPB, to cardiogenic shock hours to days after cardiac surgery, to cardiac arrest in the ICU or on

Conclusions

PC-ECMO represents the most frequent indication for temporary mechanical circulatory support with increasing use expected in the future. Considerable variability regarding surgical access and cannula placement still exists, apparently without major differences in outcomes regardless of the technique used. Although PC-ECMO can be life-saving and is only employed when there are few alternatives, mortality and morbidity remain high, reflecting underlying disease severity and an imperfect solution.

Disclosure statement

R.L. is a consultant and conducts clinical trial for LivaNova (London, UK), is a consultant for Medtronic (Minneapolis, MN), and an advisory board member of PulseCath (Arnhem, The Netherlands). D.B. is on the medical advisory board for Baxter, a past medical advisory board member for ALung Technologies, and an anticipated future medical advisory board member for BREETHE. D.B. is on the Trial Steering Committee for the VENT-AVOID trial sponsored by ALung Technologies. The other authors have no

References (104)

L Bellumkonda et al.
Evolving concepts in diagnosis and management of cardiogenic shock
Am J Cardiol
(2018)
R Stretch et al.
National trends in the utilization of short-term mechanical circulatory support: incidence, outcomes, and cost analysis
J Am Coll Cardiol
(2014)
FH McCarthy et al.
Trends in U.S. extracorporeal membrane oxygenation use and outcomes: 2002-2012
Semin Thorac Cardiovasc Surg
(2015)
GJR. Whitman
Extracorporeal membrane oxygenation for the treatment of postcardiotomy shock
J Thorac Cardiovasc Surg
(2017)
MJ Jurmann et al.
Initial experience with miniature axial flow ventricular assist devices for postcardiotomy heart failure
Ann Thorac Surg
(2004)
SM Fiser et al.
When to discontinue extracorporeal membrane oxygenation for postcardiotomy support
Ann Thorac Surg
(2001)
NG Smedira et al.
Postcardiotomy mechanical support: risk factors and outcomes
Ann Thorac Surg
(2001)
WJ Ko et al.
Extracorporeal membrane oxygenation support for adult postcardiotomy cardiogenic shock
Ann Thorac Surg
(2002)
F Bakhtiary et al.
Venoarterial extracorporeal membrane oxygenation for treatment of cardiogenic shock: clinical experiences in 45 adult patients
J Thorac Cardiovasc Surg
(2008)
HA Elsharkawy et al.
Outcome in Patients Who Require Venoarterial Extracorporeal Membrane Oxygenation Support After Cardiac Surgery
J Cardio-Thorac Vasc Anesth
(2010)

I Slottosch et al.

Outcomes after peripheral extracorporeal membrane oxygenation therapy for postcardiotomy cardiogenic shock: a single-center experience

J Surg Res

(2013)

CL Li et al.

The early dynamic behavior of lactate is linked to mortality in postcardiotomy patients with extracorporeal membrane oxygenation support: a retrospective observational study

J Thorac Cardiovasc Surg

(2015)

P Saxena et al.

Extracorporeal membrane oxygenation support in postcardiotomy elderly patients: the Mayo Clinic experience

Ann Thorac Surg

(2015)

K Distelmaier et al.

Cardiac arrest does not affect survival in post-operative cardiovascular surgery patients undergoing extracorporeal membrane oxygenation

Resuscitation

(2016)

MA Mazzeffi et al.

Outcomes of extracorporeal cardiopulmonary resuscitation for refractory cardiac arrest in adult cardiac surgery patients

J Thorac Cardiovasc Surg

(2016)

C Smith et al.

An extracorporeal membrane oxygenation-based approach to cardiogenic shock in an older population

Ann Thorac Surg

(2001)

S Saito et al.

Is extracorporeal life support contraindicated in elderly patients?

Ann Thorac Surg

(2007)

GM Raffa et al.

Meta-analysis of peripheral or central ECMO in postcardiotomy and non-postcardiotomy shock

Ann Thorac Surg

(2019)

BJ Carroll et al.

Clinical features and outcomes in adults with cardiogenic shock supported by extracorporeal membrane oxygenation

Am J Cardiol

(2015)

V Tarzia et al.

Extracorporeal life support in cardiogenic shock: impact of acute versus chronic etiology on outcome

J Thorac Cardiovasc Surg

(2015)

H Takayama et al.

Clinical outcome of mechanical circulatory support for refractory cardiogenic shock in the current era

J Heart Lung Transplant

(2013)

A Xie et al.

Venoarterial extracorporeal membrane oxygenation for cardiogenic shock and cardiac arrest: a metanalysis

J Cardio-Thorac Vasc Anesth

(2015)

NK Chou et al.

Extracorporeal membrane oxygenation to rescue cardiopulmonary failure after heart transplantation: a single-center experience

Transplant Proceed

(2010)

DR Listijono et al.

Usefulness of extracorporeal membrane oxygenation for early cardiac allograft dysfunction

J Heart Lung Transplant

(2011)

M Dandel et al.

Left ventricular versus biventricular mechanical support: decision making and strategies for avoidance of right heart failure after left ventricular assist device implantation

Int J Cardiol

(2015)

Y Zhao et al.

Extracorporeal cardiopulmonary resuscitation for adult patients who underwent post-cardiac surgery

Eur J Med Res

(2015)

DN Ranney et al.

Central cannulation as a viable alternative to peripheral cannulation in extracorporeal membrane oxygenation

Semin Thorac Cardiovasc Surg

(2017)

JL Navia et al.

Extracorporeal membrane oxygenation with right axillary artery perfusion

Ann Thorac Surg

(2005)

M Biscotti et al.

The ”Sport Model”: extracorporeal membrane oxygenation using the subclavian artery

Ann Thorac Surg

(2014)

A. Babu

Techniques of venoarterial ECMO support and conversion to temporary LVAD

Op Tech Thorac CardioVasc Surg

(2014)

JJ Russo et al.

Left ventricular unloading during extracorporeal membrane oxygenation in patients with cardiogenic shock

J Am Coll Cardiol

(2019)

S Tepper et al.

Left ventricular unloading by Impella device versus surgical vent during extracorporeal life support

Ann Thorac Surg

(2017)

B Schrage et al.

Unloading of the left ventricle during venoarterial extracorporeal membrane oxygenation therapy in cardiogenic shock

J Am Coll Cardiol HF

(2018)

JW. Haft

Temporary mechanical circulatory support for postcardiotomy shock: don't come late to the party

J Thorac Cardiovasc Surg

(2015)

K Distelmaier et al.

Beneficial effects of levosimendan on survival in patients undergoing extracorporeal membrane oxygenation after cardiovascular surgery

Brit J Anaesth

(2016)

K Distelmaier et al.

Duration of extracorporeal membrane oxygenation support and survival in cardiovascular surgery patients

J Thorac Cardiovasc Surg

(2018)

R Cheng et al.

Complications of extracorporeal membrane oxygenation for treatment of cardiogenic shock and cardiac arrest: a meta-analysis of 1,866 adult patients

Ann Thorac Surg

(2014)

R Lorusso et al.

Venoarterial extracorporeal membrane oxygenation for refractory cardiogenic shock in elderly patients: trends in application and outcome from the extracorporeal life support organization (ELSO) registry

Ann Thorac Surg

(2017)

SF Marasco et al.

Extracorporeal membrane oxygenation in primary graft failure after heart transplantation

Ann Thorac Surg

(2010)

A Rubino et al.

Central veno-arterial extracorporeal membrane oxygenation (C-VA-ECMO) after cardiothoracic surgery: a single-center experience

J Cardio Thoraxc Vasc Anesth

(2018)

PB Rahmanian et al.

Predicting hospital mortality and analysis of long-term survival after major noncardiac complications in cardiac surgery patients

Ann Thorac Surg

(2010)

RS Stephens et al.

Lung injury and acute respiratory distress syndrome after cardiac surgery

Ann Thorac Surg

(2013)

GJ Peek et al.

Efficacy and economic assessment of conventional ventilatory support versus extracorporeal membrane oxygenation for severe adult respiratory failure (CESAR): a multicentre randomised controlled trial

Lancet

(2009)

CM Sauer et al.

Extracorporeal membrane oxygenation use has increased by 433% in adults in the United States from 2006 to 2011

ASAIO J

(2015)

BG Maxwell et al.

Resource use trends in extracorporeal membrane oxygenation in adults: an analysis of the Nationwide Inpatient Sample 1998-2009

J Thorac Cardiovasc Surg

(2014)

DJ Goldstein et al.

Mechanical support for postcardiotomy cardiogenic shock

Semin Thorac Cardiovasc Surg

(2000)

JJ Curtis et al.

Postcardiotomy centrifugal assist: a single surgeon's experience

Artif Organs

(2002)

AF Hernandez et al.

A decade of short-term outcomes in post cardiac surgery ventricular assist device implantation: data from the Society of Thoracic Surgeons’ National Cardiac Database

Circulation

(2007)

MH Akay et al.

Timely use of a CentriMag heart assist device improves survival in postcardiotomy cardiogenic shock

J Card Surg

(2011)

EA Sylvin et al.

Mechanical support for postcardiotomy cardiogenic shock: has progress been made?

J Card Surg

(2010)

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Postcardiotomy Shock Syndrome: A Narrative Review of Perioperative Diagnosis and Management
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Postcardiotomy shock (PCS) is generally described as the inability to separate from cardiopulmonary bypass due to ineffective cardiac output after cardiotomy, which is caused by a primary cardiac disorder, resulting in inadequate tissue perfusion. Postcardiotomy shock occurs in 0.5% to 1.5% of contemporary cardiac surgery cases, and is accompanied by an in-hospital mortality of approximately 67%. In the last 2 decades, the incidence of PCS has increased, likely due to the increased age and baseline morbidity of patients requiring cardiac surgery. In this narrative review, the authors discuss the epidemiology and pathophysiology of PCS, the rationale and evidence behind the initiation, continuation, escalation, and discontinuation of mechanical support devices in PCS, and the anesthetic implications.
The importance of timing in postcardiotomy venoarterial extracorporeal membrane oxygenation: A descriptive multicenter observational study
2023, Journal of Thoracic and Cardiovascular Surgery
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.
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.
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).
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.
On-Support and Postweaning Mortality in Postcardiotomy Extracorporeal Membrane Oxygenation
2023, Annals of Thoracic Surgery
Postcardiotomy venoarterial extracorporeal membrane oxygenation (VA ECMO) is characterized by discrepancies between weaning and survival-to-discharge rates. This study analyzes the differences between postcardiotomy VA ECMO patients who survived, died on ECMO, or died after ECMO weaning. Causes of death and variables associated with mortality at different time points are investigated.
The retrospective, multicenter, observational Postcardiotomy Extracorporeal Life Support Study (PELS) includes adults requiring postcardiotomy VA ECMO between 2000 and 2020. Variables associated with on-ECMO mortality and postweaning mortality were modeled using mixed Cox proportional hazards, including random effects for center and year.
In 2058 patients (men, 59%; median age, 65 years; interquartile range [IQR], 55-72 years), weaning rate was 62.7%, and survival to discharge was 39.6%. Patients who died (n = 1244) included 754 on-ECMO deaths (36.6%; median support time, 79 hours; IQR, 24-192 hours), and 476 postweaning deaths (23.1%; median support time, 146 hours; IQR, 96-235.5 hours). Multiorgan (n = 431 of 1158 [37.2%]) and persistent heart failure (n = 423 of 1158 [36.5%]) were the main causes of death, followed by bleeding (n = 56 of 754 [7.4%]) for on-ECMO mortality and sepsis (n = 61 of 401 [15.4%]) for postweaning mortality. On-ECMO death was associated with emergency surgery, preoperative cardiac arrest, cardiogenic shock, right ventricular failure, cardiopulmonary bypass time, and ECMO implantation timing. Diabetes, postoperative bleeding, cardiac arrest, bowel ischemia, acute kidney injury, and septic shock were associated with postweaning mortality.
A discrepancy exists between weaning and discharge rate in postcardiotomy ECMO. Deaths occurred during ECMO support in 36.6% of patients, mostly associated with unstable preoperative hemodynamics. Another 23.1% of patients died after weaning in association with severe complications. This underscores the importance of postweaning care for postcardiotomy VA ECMO patients.
Temporary circulatory support with surgically implanted microaxial pumps in postcardiotomy cardiogenic shock following coronary artery bypass surgery
2023, JTCVS Open
Patients with ischemic cardiomyopathy undergoing coronary artery bypass grafting (CABG) surgery may develop postcardiotomy cardiogenic shock. In these cases, implantation of an Impella 5.0 or 5.5 microaxial pump offers full hemodynamic support while simultaneously unloading of the left ventricle.
Preoperative, perioperative, and postoperative data of all patients receiving postoperative support with an Impella 5.0 or 5.5 after CABG surgery between September 2017 and October 2022 were retrospectively collected. Cohort built-up was performed according to the timing of Impella implantation, either simultaneous during CABG surgery or delayed.
A total of n = 42 patients received postoperative Impella support, of whom 27 patients underwent simultaneous Impella implantation during CABG surgery and 15 patients underwent delayed Impella therapy. Preoperative left ventricular ejection fraction was similarly low in both groups (26.7 ± 0.7% vs 24.8 ± 11.3%; P = .32). In the delayed cohort, Impella implantation was performed after a median of 1 (1; 2) days after CABG surgery. Survival after 30 days (75.6% vs 47.6%, P = .04) and 1 year (69.4% vs 29.8%, P = .03) was better in the cohort receiving simultaneous Impella implantation.
The combined advantages of hemodynamic support and LV unloading with microaxial pumps may lead to a favorable survival in patients with left ventricular failure following CABG surgery. Early implantation during the initial surgery shows a trend toward a more favorable survival as compared with patients receiving delayed support.
The International Society for Heart and Lung Transplantation/Heart Failure Society of America Guideline on Acute Mechanical Circulatory Support
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In spite of medical advances, cardiogenic and pulmonary shock are associated with high mortality and morbidity. The availability and use of acute or temporary mechanical support devices has grown over the years, with the goal of improving patient outcomes by temporarily providing support to allow time for organ recovery or for longer-term decisions including transition to durable therapies. A collaborative effort commissioned by the International Society of Heart and Lung Transplantation and the Heart Failure Society of America has developed this critically-needed guideline for the management of patients requiring acute mechanical circulatory support (MCS). The document covers definitions of cardiogenic and pulmonary shock, medical treatment and surgical interventions, management of patients supported with temporary devices, complications, special populations, and social and ethical dilemmas. The writing groups include multidisciplinary members from both societies with a focus on diversity in gender, geography, area of expertise and level of seniority. The target audience includes cardiologists, especially interventional and advanced heart failure, pulmonarycritical care specialists, intensivists, cardiothoracic surgeons, as well as referring providers.
The International Society for Heart and Lung Transplantation/Heart Failure Society of America Guideline on Acute Mechanical Circulatory Support
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¹: These authors contributed equally to this work.

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STATE OF ARTStructured review of post-cardiotomy extracorporeal membrane oxygenation: part 1—Adult patients

Section snippets

Trends in use

Cannulation

Weaning from PC-ECMO and survival to hospital discharge

Post-cardiotomy veno-venous ECMO for respiratory dysfunction

Controversial issues and future perspectives on PC-ECMO

Limitations of the review

Conclusions

Disclosure statement

Am J Cardiol

J Am Coll Cardiol

Semin Thorac Cardiovasc Surg

J Thorac Cardiovasc Surg

Ann Thorac Surg

Ann Thorac Surg

Ann Thorac Surg

Ann Thorac Surg

J Thorac Cardiovasc Surg

J Cardio-Thorac Vasc Anesth

J Surg Res

J Thorac Cardiovasc Surg

Ann Thorac Surg

Resuscitation

J Thorac Cardiovasc Surg

Ann Thorac Surg

Ann Thorac Surg

Ann Thorac Surg

Am J Cardiol

J Thorac Cardiovasc Surg

J Heart Lung Transplant

J Cardio-Thorac Vasc Anesth

Transplant Proceed

J Heart Lung Transplant

Int J Cardiol

Eur J Med Res

Semin Thorac Cardiovasc Surg

Ann Thorac Surg

Ann Thorac Surg

Op Tech Thorac CardioVasc Surg

J Am Coll Cardiol

Ann Thorac Surg

J Am Coll Cardiol HF

J Thorac Cardiovasc Surg

Brit J Anaesth

J Thorac Cardiovasc Surg

Ann Thorac Surg

Ann Thorac Surg

Ann Thorac Surg

J Cardio Thoraxc Vasc Anesth

Ann Thorac Surg

Ann Thorac Surg

Lancet

Extracorporeal membrane oxygenation use has increased by 433% in adults in the United States from 2006 to 2011

ASAIO J

Resource use trends in extracorporeal membrane oxygenation in adults: an analysis of the Nationwide Inpatient Sample 1998-2009

J Thorac Cardiovasc Surg

Mechanical support for postcardiotomy cardiogenic shock

Semin Thorac Cardiovasc Surg

Postcardiotomy centrifugal assist: a single surgeon's experience

Artif Organs

A decade of short-term outcomes in post cardiac surgery ventricular assist device implantation: data from the Society of Thoracic Surgeons’ National Cardiac Database

Circulation

Timely use of a CentriMag heart assist device improves survival in postcardiotomy cardiogenic shock

J Card Surg

Mechanical support for postcardiotomy cardiogenic shock: has progress been made?

J Card Surg

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