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Extracorporeal Membrane Oxygenation Support in Refractory Cardiogenic Shock: Treatment Strategies and Analysis of Risk Factors
Author(s) -
Loforte Antonio,
Marinelli Giuseppe,
Musumeci Francesco,
Folesani Gianluca,
Pilato Emanuele,
Martin Suarez Sofia,
Montalto Andrea,
Lilla Della Monica Paola,
Grigioni Francesco,
Frascaroli Guido,
Menichetti Antonio,
Di Bartolomeo Roberto,
Arpesella Giorgio
Publication year - 2014
Publication title -
artificial organs
Language(s) - English
Resource type - Journals
SCImago Journal Rank - 0.684
H-Index - 76
eISSN - 1525-1594
pISSN - 0160-564X
DOI - 10.1111/aor.12317
Subject(s) - cardiogenic shock , extracorporeal membrane oxygenation , medicine , packed red blood cells , myocardial infarction , creatine kinase , cardiology , heart transplantation , heart failure , ventricular assist device , surgery , anesthesia , blood transfusion
Two centrifugal pumps, the R ota F low ( M aquet, J ostra M edizintechnik AG , H irrlingen, G ermany) and L evitronix C entri M ag ( L evitronix LCC , W altham, MA , USA ), used in central or peripheral veno‐arterial extracorporeal membrane oxygenation ( ECMO ) support systems have been investigated, in terms of double‐center experience, as treatment for patients with refractory cardiogenic shock ( CS ). Between J anuary 2006 and D ecember 2012, 228 consecutive adult patients were supported on R ota F low ( n = 213) or C entri M ag ( n = 15) ECMO , at our institutions (155 men; age 58.3 ± 10.5 years, range: 19–84 years). Indications for support were: failure to wean from cardiopulmonary bypass in the setting of postcardiotomy ( n = 118) and primary donor graft failure ( n = 37); postacute myocardial infarction CS ( n = 27); acute myocarditis ( n = 6); and CS on chronic heart failure ( n = 40). A peripheral ECMO setting was established in 126 (55.2%) patients while it was established centrally in 102 (44.7%). Overall mean support time was 10.9 ± 9.7 days (range: 1–43 days). Eighty‐four (36.8%) patients died on ECMO . Overall success rate, in terms of survival on ECMO ( n = 144), weaning from mechanical support ( n = 107; 46.9%), bridge to mid‐long‐term ventricular assist device ( n = 6; 2.6%), and bridge to heart transplantation ( n = 31; 13.5%), was 63.1%. One hundred twenty‐two (53.5%) patients were successfully discharged. Stepwise logistic regression identified blood lactate level and MB isoenzyme of creatine kinase ( CK‐MB ) relative index at 72 h after ECMO initiation, and number of packed red blood cells ( PRBCs ) transfused on ECMO as significant predictors of mortality on ECMO ( P = 0.010, odds ratio [ OR ] = 2.94; 95% confidence interval [ CI ] = 1.10–3.14; P = 0.010, OR = 2.82, 95% CI = 1.014–3.721; and P = 0.011, OR = 2.69; 95% CI = 1.06–4.16, respectively). Central ECMO population had significantly higher rate of continuous veno‐venous hemofiltration need and bleeding requiring surgery events compared with the peripheral ECMO setting population. No significant differences were seen by comparing the R ota F low and C entri M ag populations in terms of device performance. At follow‐up, persistent heart failure with left ventricle ejection fraction ( LVEF ) ≤40% was a risk factor after hospital discharge. Patients with a poor hemodynamic status may benefit from rapid central or peripheral insertion of ECMO . The blood lactate level, CK‐MB relative index, and PRBCs transfused should be strictly monitored during ECMO support. In addition, early ventricular assist device placement or urgent listing for heart transplant should be considered in patients with persistent impaired LVEF after ECMO .