Venoarterial Extracorporeal Membrane Oxygenation for Refractory Cardiogenic Shock in Elderly Patients: Trends in Application and Outcome From the Extracorporeal Life Support Organization (ELSO) Registry.

Venoarterial extracorporeal membrane oxygenation (VA-ECMO) for refractory cardiogenic shock (RCS) is increasingly used in adult patients, but age represents a controversial factor in this setting. Data from the Extracorporeal Life Support Organization registry was analyzed to assess in-hospital survival of elderly patients (≥70 years of age) undergoing VA-ECMO for RCS from 1992 to 2015. In-hospital survival and complications for elderly patients were compared with data in younger adults (≥18 to <70 years of age) supported with VA-ECMO during the same time period for similar indications. The mean age of the patient cohort (n = 5,408) was 53.0 ± 15.7 years (range, 18 to 91 years). The elderly group included 735 patients (13.6%), with a mean age of 75.2 ± 4.4 years. In the elderly group, pre-ECMO cardiac procedures were performed in 134 cases (18.9%), and 2.2% received VA-ECMO for postcardiotomy support compared with 0.7% in the younger cohort. The mean duration of VA-ECMO in the elderly group was 101 ± 91 h compared with 138 ± 146 h in the younger group (p < 0.001). Overall, survival to hospital discharge for the entire adult cohort was 41.4% (2,240 of 5,408), with 30.5% (224 of 735) in the elderly patient group and 43.1% (2,016 of 4,673) in the younger patient group (p < 0.001). Elderly patients had a higher rate of multiorgan failure. At multivariable analysis age represented an independent negative predictor of in-hospital survival. Based on the acceptable survival to hospital discharge in our study, older age alone should not represent an absolute contraindication when considering VA-ECMO support for RCS.

Lorusso R ，Gelsomino S ，Parise O ，Mendiratta P ，Prodhan P ，Rycus P ，MacLaren G ，Brogan TV ，Chen YS ，Maessen J ，Hou X ，Thiagarajan RR ... -  《-》

Clinical utility of venoarterial-extracorporeal membrane oxygenation (VA-ECMO) in patients with drug-induced cardiogenic shock: a retrospective study of the Extracorporeal Life Support Organizations' ECMO case registry.

Weiner L ，Mazzeffi MA ，Hines EQ ，Gordon D ，Herr DL ，Kim HK ... -  《-》

Mechanical support with venoarterial extracorporeal membrane oxygenation (ECMO-VA): Short-term and long-term prognosis after a successful weaning.

Extracorporeal membrane oxygenation (ECMO) affords mechanical circulatory assistance associated to high mortality. However, weaning from such mechanical support may not imply improved short- or long-term survival. This study describes the characteristics and evolution of patients with refractory cardiogenic shock (RCS) subjected to venoarterial ECMO (VA-ECMO) in a hospital with a heart transplant program. A single-center, retrospective cohort study was carried out. The cardiovascular ICU of a tertiary hospital. Forty-six patients consecutively subjected to VA-ECMO over 6 years. Hospital mortality after weaning from ECMO and overall survival (OS) were analyzed. Fifteen patients (33%) died with VA-ECMO and 31 (67%) were weaned after 8 days of support (IQR: 5-15). Fourteen patients under went transplantation. Hospital mortality in these patients was 32% (10/31), and was associated to age (P=.001), SAPS II score (P=.009), cannulation bleeding (P=.01) and post-acute myocardial infarction RCS (P=.001). After a median follow-up of 27 months (IQR: 11-49), 91% of the patients discharged from hospital were still alive. Overall survival after weaning from assistance was associated to the type of cardiac disease (P=.002). Patients with RCS after acute myocardial infarction had a poorer prognosis. In our experience, VA-ECMO can be used as mechanical assistance in the management of RCS. The technique is associated to high early mortality, though the long-term survival rate after hospital discharge is good.

García-Gigorro R ，Renes-Carreño E ，Pérez-Vela JL ，Marín-Mateos H ，Gutiérrez J ，Corrés-Peiretti MA ，Delgado JF ，Pérez-de la Sota E ，Cortina-Romero JM ，Montejo-González JC ... -  《-》

The use of extracorporeal membrane oxygenation in the setting of postinfarction mechanical complications: outcome analysis of the Extracorporeal Life Support Organization Registry.

Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) has been recently considered and used for patients with post-acute myocardial infarction mechanical complications (post-AMI MC); however, information in this respect is scarce. The purpose of this study was to evaluate the in-hospital outcomes of patients with post-AMI MC submitted to VA-ECMO, and enrolled in the Extracorporeal Life Support Organizations (ELSO)'s data Registry. This was a retrospective review of the ELSO Registry to identify adult (>18 years old) patients with post-AMI MC who underwent VA-ECMO support between 2007 and 2018. The primary end point of this study was in-hospital survival. ECMO complications were also evaluated. The patient cohort available for this study included 158 patients. The median age was 62.4 years (range 20-80). The most common post-AMI MC was ventricular septal rupture (n = 102; 64.5%), followed by papillary muscle rupture (n = 42; 26.6%) and ventricular free-wall rupture (n = 14; 8.9%). Approximately a quarter of patients (n = 41; 25.9%) had cardiac arrest before VA-ECMO institution. The median duration of VA-ECMO was 5.9 days (range 1 h-40.3 days). ECMO complications occurred in 119 patients (75.3%). Overall, survival to hospital discharge for the entire patient cohort was 37.3%. Patients who had ventricular septal rupture as primary diagnosis had higher in-hospital mortality (n = 66; 64.7%). In patients with post-AMI MC, VA-ECMO provides haemodynamic stabilizations and carries a potential to reverse otherwise lethal course. ECMO complications, however, remain an important limitation. Further investigations are required to better evaluate the efficacy and safety of ECMO in this context.

Matteucci M ，Fina D ，Jiritano F ，Meani P ，Raffa GM ，Kowalewski M ，Aldobayyan I ，Turkistani M ，Beghi C ，Lorusso R ... -  《-》

VA-ECMO Support in Nonsurgical Patients With Refractory Cardiogenic Shock: Pre-Implant Outcome Predictors.

Refractory cardiogenic shock (RCS) is associated with a high mortality. Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is increasingly used as acute cardiopulmonary support but selection of VA-ECMO candidates remains challenging. There are limited data on which pre-VA-ECMO variables that predict outcome. The aim of this study was to identify pre-VA-ECMO predictors of 90-day mortality. We retrospectively analyzed 76 consecutive patients (median age 52; interquartile range [IQR]: 37-60) supported with VA-ECMO due to RCS. The association between pre-implant variables and all-cause mortality at 90 days was analyzed with multivariable logistic regression. Main etiologies of RCS were acute myocardial infarction 51% and other AHF etiologies 49%. Cardiopulmonary resuscitation was performed in 54% of patients before initiation of VA-ECMO. Median duration of VA-ECMO was 5 days (IQR: 2-11). The 90-day overall mortality was 49% and in-hospital mortality was 50%; 46% died on VA-ECMO, 37% were successfully weaned, 13% were bridged to heart transplantation, and 4% to left ventricular assist device. Multivariable logistic regression analysis identified arterial lactate (odds ratio [OR] per mmol/L: 1.15; 95% confidence interval [CI]: 1.06-1.24; P = 0.001) and number of inotropes and vasopressors (OR per agent: 2.14; 95% CI: 1.26-3.63; P = 0.005) as independent predictors of 90-day mortality. In RCS patients arterial lactate level and number of inotropes and vasopressors were identified as independent pre-VA-ECMO predictors of 90-day mortality. Thus, the severity of cardiogenic shock expressed as levels of lactate and vasoactive agents just before start of VA-ECMO may be more predictive of outcome than the specific etiology of cardiogenic shock.

Fux T ，Holm M ，Corbascio M ，Lund LH ，van der Linden J ... -  《-》