Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) for emergency cardiac support.
Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) may provide benefit to patients in refractory cardiac arrest and cardiogenic shock. We aim to summarize our center's 6-year experience with resuscitative VA-ECMO.
A retrospective medical record review (April 2009 to 2015) was performed on consecutive non-cardiotomy patients who were managed with VA-ECMO due to refractory in- or out-of-hospital cardiac (IHCA/OHCA) arrest (E-CPR) or refractory cardiogenic shock (E-CS) with or without preceding cardiac arrest. Our primary outcome was survival to hospital discharge and good neurological status (Cerebral Performance Category 1-2).
There were a total of 22 patients who met inclusion criteria of whom 9 received E-CPR (8 IHCA, 1 OHCA) and 13 received E-CS. The median age for E-CPR patients was 52 [IQR 45, 58] years, and 54 [IQR 38, 64] years for E-CS patients. Cardiac arrest duration was 70.33 (SD 39.56) min for the E-CPR patients, and 24.67 (SD 26.73) min for the 9 patients treated with E-CS who had previously arrested. Initial cardiac arrest rhythms were pulseless electrical activity (39%), ventricular fibrillation (33%), or ventricular tachycardia (28%). A total of 18/22 patients were successfully weaned from VA-ECMO (78%); 16 patients survived to hospital discharge (73%) with 15 in good neurological condition.
The initiation of VA-ECMO at our center for treatment of refractory cardiac arrest and cardiogenic shock yielded a high proportion of survivors and favorable neurological outcomes.
Sun T
，Guy A
，Sidhu A
，Finlayson G
，Grunau B
，Ding L
，Harle S
，Dewar L
，Cook R
，Kanji HD
... -
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Post-cardiac arrest shock treated with veno-arterial extracorporeal membrane oxygenation: An observational study and propensity-score analysis.
Cardiogenic shock due to post-resuscitation myocardial dysfunction is a major cause of mortality among patients hospitalized after cardiac arrest (CA). Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) has been proposed in the most severe cases but the level of evidence is very low. We assessed characteristics, outcome and prognostic factors of patients treated with VA-ECMO for post-CA shock.
Using a large regional registry, we focused on all CA admitted in ICU. Among those who developed a post-CA shock, prognostic was compared according to VA-ECMO use, using logistic regression and propensity score. Specific prognostic factors were identified among VA-ECMO patients.
Among 2988 patients admitted after CA, 1489 developed a post-CA shock, and were included. They were mostly male (68%), with mean age 63 years (SD=15). Fiflty-two patients (3.5%) were treated with VA-ECMO, mostly patients with ischemic cause of CA (67%). Among patients with post-CA shock, 312 (21%) were discharged alive (25% in VA-ECMO group, 21% in control group, P=0.45). After adjustment for pre-hospital and in-hospital factors, survival did not differ among patients treated with VA-ECMO (OR for survival=0.9, 95%CI 0.4-2.3, P=0.84). After propensity-score matching, results were consistent. Among patients treated with VA-ECMO, initial arterial pH (OR=1.7 per 0.1 increase, 95%CI 1.0-2.8, P=0.04) and implantation of VA-ECMO over 24h after ROSC (OR=20.0, 95%CI 1.4-277.3, P=0.03) were associated with survival.
Post-CA shock is frequent and is associated with a high mortality rate. When used in selected patients, we observed that VA-ECMO could be an appropriate treatment.
Bougouin W
，Aissaoui N
，Combes A
，Deye N
，Lamhaut L
，Jost D
，Maupain C
，Beganton F
，Bouglé A
，Karam N
，Dumas F
，Marijon E
，Jouven X
，Cariou A
，SDEC Investigators
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Extracorporeal Membrane Oxygenation for Cardiac Indications in Adults: A Health Technology Assessment.
Extracorporeal membrane oxygenation (ECMO) is a rescue therapy used to stabilize patients with hemodynamic compromise such as refractory cardiogenic shock or cardiac arrest. When used for cardiac arrest, ECMO is also known as extracorporeal cardiopulmonary resuscitation (ECPR). We conducted a health technology assessment of venoarterial ECMO for adults (aged ≥ 18 years) with cardiac arrest refractory to conventional cardiopulmonary resuscitation (CPR) or with cardiogenic shock refractory to conventional medical management (i.e., drugs, mechanical support such as intra-aortic balloon pump and temporary ventricular assist devices). Our assessment included an evaluation of effectiveness, safety, cost-effectiveness, the budget impact of publicly funding ECMO for these indications, and patient preferences and values.
We performed a systematic literature search of the clinical evidence. We assessed the risk of bias of each included study using the Risk of Bias in Systematic Reviews (ROBIS) tool for systematic reviews and the Risk of Bias Among Nonrandomized Trials (ROBINS-I) tool for observational studies, and the quality of the body of evidence according to the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) Working Group criteria. We performed a systematic economic literature search and conducted a cost-effectiveness analysis with a lifetime horizon from a public payer perspective. We also analyzed the budget impact of publicly funding ECMO in Ontario for patients with refractory cardiogenic shock or cardiac arrest. To contextualize the potential value of ECMO for cardiac indications, we spoke with patients and caregivers with direct experience with the procedure.
We included one systematic review (with 13 observational studies) and two additional observational studies in the clinical review. Compared with traditional CPR for patients with refractory cardiac arrest, ECPR was associated with significantly improved 30-day survival (pooled risk ratio [RR] 1.54; 95% CI 1.03 to 2.30) (GRADE: Very Low) and significantly improved long-term survival (pooled RR 2.17; 95% CI 1.37 to 3.44) (GRADE: Low). Overall, ECPR was associated with significantly improved 30-day favourable neurological outcome in patients with refractory cardiac arrest compared with traditional CPR; pooled RR 2.02 (95% CI 1.29 to 3.16) (GRADE: Very Low). For patients with cardiogenic shock, ECMO was associated with a significant improvement in 30-day survival compared with intra-aortic balloon pump (pooled RR 2.11; 95% CI 1.23 to 3.61) (GRADE: Very Low). Compared with temporary percutaneous ventricular assist devices, ECMO was not associated with improved survival (pooled risk ratio 0.94; 95% CI 0.67 to 1.30) (GRADE: Very Low).We estimated the incremental cost-effectiveness ratio of ECPR compared with conventional CPR is $18,722 and $28,792 per life-year gained (LYG) for in-hospital and out-of-hospital cardiac arrest, respectively. We estimated the probability of ECPR being cost-effective versus conventional CPR is 93% and 60% at a willingness-to-pay of $50,000 per LYG for in-hospital and out-of-hospital cardiac arrest, respectively. We estimate that publicly funding ECMO in Ontario over the next 5 years would result in additional total costs of $1,673,811 for cardiogenic shock (treating 314 people), $2,195,517 for in-hospital cardiac arrest (treating 126 people), and $3,762,117 for out-of-hospital cardiac arrest (treating 247 people).The eight patients and family members with whom we spoke had limited ability to assess the impact of ECMO or report their impressions because of their critical medical situations when they encountered the procedure. All had been in hospital with acute hemodynamic instability. In the decision to receive the procedure, participants generally relied on the expertise and judgment of physicians.
For adults treated for refractory cardiac arrest, ECPR may improve survival and likely improves long-term neurological outcomes compared with conventional cardiopulmonary resuscitation. For patients treated for cardiogenic shock, ECMO may improve 30-day survival compared with intra-aortic balloon pump, but there is considerable uncertainty.For adults with refractory cardiac arrest, ECPR may be cost-effective compared with conventional CPR. We estimate that publicly funding ECMO for people with cardiac arrest and cardiogenic shock in Ontario over the next 5 years would cost about $845,000 to $2.2 million per year.People with experience of ECMO for cardiac indications viewed it as a life-saving device and expressed gratitude that it was available and able to help stabilize their acute medical condition.
Ontario Health (Quality)
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