Table 1.
Summary of outcomes of studies examining patients with PCCS treated with VA-ECMO
| Author (year published) & country | Historical period | Number of patients & Indications for surgery | Outcomes with key results | Comments |
|---|---|---|---|---|
| Khorsandi et al. [29] (2015), United Kingdom | 4/1995–4/2015 | 15 patients -AVR (n = 3) -CABG (n = 3) -CABG & AVR (n = 1) -Aortic dissection/transection (n = 3) -MV repair/MVR & CABG (n = 2) -Miscellaneous (n = 3) |
Age range: 34–83 years (median 71) 30-day survival: 37.5% Survival to hospital discharge: 31.25% 24-month survival: 31.25 Functional status: NYHA status I-II |
Authors reported acceptable functional outcome post VA-ECMO Weaknesses: limited sample size; retrospective study |
| Doll et al. [13] (2004), Germany | 11/1997–7/2002 | 219 patients -CABG (n = 119) -CABG & AVR (n = 240) -MVR (n = 110 -Other (n = 44) |
Average age: 61.3 years +/− 12.1 Mean period on ECMO: 2.8 +/− 2.2 days Weaned from ECMO: 61% (n = 133) 30-day mortality: 76% (n = 167) Discharged from hospital after 29 +/− 24 days: 39% (n = 52) 5-year follow-up: 74% (n = 37) were alive |
Authors concluded that VA-ECMO is an acceptable life-saving measure in high-risk patients with refractory PCCS Weaknesses: limited study size; retrospective study |
| Khorsandi et al. [20] (2016), United Kingdom | 4/1995–4/2015 | 23 patients -AVR (n = 8) -CABG (n = 6) -CABG & AVR (n = 2) -Aortic dissection/transection (n = 4) -MVR/MV repair & CABG (n = 3) |
Age range: 34–83 years (median 51) 30-day survival: 39% (n = 9) Survival to hospital discharge: 35% (n = 8) 12-month follow up: 100% survival Functional status: NYHA I-II |
Authors concluded that VA-ECMO has a high rate of systemic and device-related complications with a definite survival benefit |
| Rastan et al. [5] (2010), Germany | 5/1996–5/2008 | 516 patients: -CABG (37.4%) -CABG & AVR (16.6%) -AVR (14.3%) -Heart/lung transplant (6.5%) -Other (25%) |
Age range: 18–84 years (mean 63.5) Mean ECMO duration: 3.28 days +/− 2.85 Weaned from ECMO: 63.3% Discharged home: 24.8% Complications: 65% renal complications; 58% major bleeding requiring re-intervention; 17.4% stroke; 18% GI complications |
Authors concluded that VA-ECMO is an acceptable treatment for refractory PCCS in those patients that would otherwise die Weaknesses: limited sample size; retrospective study |
| Slottosch et al. [21] (2013), Germany | 2006–2010 | 77 patients: -CABG (n = 43) -Valve (n = 10) -CABG & Valve (n = 11) -Aortic surgery (n = 5) -Heart transplant (n = 2) -Other (n = 6) |
Mean age: 60 years +/− 13 Weaned from ECMO: 62% 30-day mortality: 70% Predictors of mortality: advanced age (p = 0.003); rising serum lactate, prolonged ECMO course and ECMO-GI complications were independent predictors of 30-day mortality (p < 0.05) Complications of ECMO: limb ischaemia (20.8%), renal failure (68.8%), & reopening for bleeding (29.9%) |
High-quality study No long-term follow-up outcomes included Needs long-term quality of life assessment |
| Hsu et al. [38] (2010), Taiwan | 1/2001–12/2006 | 51 patients: -CABG (n = 27) -Valve surgery (n = 11) -CABG & valve (n = 7) -Heart transplant (n = 4) -Other (n = 2) |
Average age: 63 years +/− 15.7 Mean duration of ECMO: 7.5 days +/− 6.7 30-day mortality: 49% 3-month mortality: 65% 1-year mortality: 71% |
Authors concluded that VA-ECMO provides good support post PCCS Study weaknesses: small sample size; longer-term follow-up required; quality of life assessment not included |
| Ko et al. [19] (2002), Taiwan | 8/1994–5/2000 | 76 patients: -CABG (n = 37) -CABG a & valve (n = 6) -Isolated valve (n = 14) -Heart transplant (n = 12) -Congenital surgery (n = 3) -LVAD (N = 2) -Aortic surgery (n = 2) |
Mean age: 56.8 years +/− 15.9 Weaned from ECMO: 60.5% (n = 46) Survival to hospital discharge: 26.3% (n = 20) Functional status: all survivors NYHA I-II on follow-up period of 33+/−22 months |
Strengths: good intermediate-term follow-up Weaknesses: small sample size |
| Muehrcke et al. [3] (1996), USA | 9/1992–7/1994 | 22 patients: -CABG (n = 8) -Valve (n = 6) -Heart transplant (n = 4) -Post-infarction VSD (n = 2) -Miscellaneous (n = 2) |
Average age: 47.3 years +/− 16.4 (range 5–72) Weaned from ECMO: 30.4% (n = 7) Subsequent heart transplant: 13.6% (n = 3) Complications: major haemorrhage, leg ischaemia, renal failure, thrombus formation, and stroke |
Weaknesses: limited sample size, no long-term follow-up data |
| Santarpino et al. [14] (2015), multicenter European study | 2005–2015 | 20 patients, from 11 European centers -CABG (n = 85) |
Average age: 64.6 years +/− 10.3 Survival to hospital discharge: 40% (n = 8) 1-year survival: 29.3% Complications: stroke (40%), reopening for bleeding (60%), dialysis for renal failure (35%), DSWI (30%) |
Salvage CABG has high rate of immediate mortality ECMO for refractory PCCS has encouraging results |
| Saeed et al. [39] (2015), Germany | 1/2013–7/2014 | 9 patients: -CABG & valve replacement (n = 5) -CABG (n = 4) |
Average age: 65 years +/− 14 Weaned from ECMO: 44% (n = 4) Survival to hospital discharge: 22% (n = 2) Complications: renal failure (89%, n = 8) |
Weaknesses: small sample size |
| Sajjad et al. [40] (2012), Saudi Arabia | 1/2007–12/2009 | 19 patients: - Emergency (n = 11) -Urgently (n = 5) -Electively (n = 3) |
Age range: 21–79 years (mean 55.6) Unable to wean (died on ECMO): 63% (n = 12) 30-day mortality: 94.7% Survival to hospital discharge: 5.3% |
Authors concluded that ECMO is costly, prolongs ICU stay and delays imminent death in most patients |
| Mikus et al. [22] (2013), Italy | 2007–2014 | 14 patients: -AVR and/or MVR (n = 6) -CABG (n = 6) -Bentall procedure (n = 3) |
Mean age: 53.1 years +/− 14.3 (range 25–70) Successful weaning: 50% (n = 7) Survival to hospital discharge: 42.8% (n = 6) Complications: mediastinal bleeding (64.3%), renal failure (50%), sepsis (42.8%), pneumonia (28.6%) |
Authors concluded that VA-ECMO with Levitronix CentriMagR is a reliable and easy to apply life-saving mechanical support which can be applied to bridge postcardiotomy patients to decision |
| Unosawa et al. [27] (2013), Japan | 04/1992–06/2007 | 47 patients: -CABG (n = 19) -Valve (n = 8) -CABG & Valve (n = 2) -Aortic surgery (n = 5) -Valve & aortic surgery (n = 1) -Aortic surgery & CABG (n = 3) -Aortic root replacement (n = 2) -Post-infarction VSD (n = 5) Pulmonary embolectomy (n = 2) |
Average age: 64.4 years +/− 12.5 (range 22–83) Weaned from ECMO: 60.7% (n = 29) Survival to hospital discharge: 48% (n = 14) 30-day survival: 34% 1-year survival: 29.8% 10-year survival: 17.6% Independent risk factors for mortality: incomplete sternal closure (p = 0.049) and ECMO duration >48 h (p = 0.027) |
Authors concluded that VA-ECMO for refractory PCCS is associated with high morbidly and mortality but that survivors have acceptable long-term survival Strengths: long follow-up period |
| Pokersnik et al. [41] (2012), USA | 01/2005–12/2010 | 49 patients. Group 1 (n = 11): Biomedicus pump with an affinity oxygenator Group 2 (n = 11): Biomedicus pump with a Quadrox D oxygenator Group 3 (n = 27): Rotaflow pump with a Quadrox D oxygenator |
Average age: 65 years +/− 13 Weaned from ECMO: -Group 1: 63.6% -Group 2: 45.5% -Group 3: 55.6% In-hospital survival: -Group 1: 27.3% -Group 2: 27.3% -Group 3: 33.3% |
Authors concluded that outcomes for patients undergoing ECMO for PCCS remain poor in all categories |
| Moreno et al. [42] (2011), Spain | 11/2006–12/2009 | 12 patients -Cardiac surgery (n = 8) -Heart transplant (n = 4) |
Mean age: 56.8 years (standard deviation 9.1) Mean duration on ECMO: 5.4 days Survival to hospital discharge: 50% |
Authors concluded that VA-ECMO provided viable temporary circulatory support |
| Wu et al. [17] (2010), Taiwan | 2003–2009 | 110 patients: -CABG (n = 31) -Valve (n = 16) -Multiple valves (n = 26) -Combined valve and other (n = 19) -Aortic surgery (n = 8) -Post-infarction VSD (n = 3) -Pulmonary endarterectomy (n = 4) OHT (n = 3) |
Average age: 60 years +/− 14 Weaned from ECMO: 61% (n = 67) Survival to hospital discharge: 42% (n = 46) Adverse prognostic indicators: age > 60 years, renal failure, serum bilirubin >6 mg/dL, and duration of ECMO >110 h; persistent heart failure (EF <60%) was a predictor of mortality after hospital discharge |
Authors concluded that VA-ECMO has a definite survival benefit Strengths: adverse prognostic indicators were reported |
| Elsharkawy et al. [16] (2010), USA | 1/1995–12/2005 | 233 patients: -CABG (n = 86) -Any valve (n = 69) -AVR/repair (n = 42) -MV repair/MVR (n = 44) -TV repair/TVR (n = 16) |
Survivors’ IQR: 45.1–61.4 (median 53.5) Non-survivors’ IQR: 52.1–66.3 (median 59.7) Survival to hospital discharge: 36% Associated with higher mortality rate: older age, known diabetes, CABG, longer CPB time Associated with reduced hospital morality: younger age |
Authors concluded that patient selection for salvage VA-ECMO for refractory PCCS remains difficult as the variables identified in the study are not easily modifiable and do not appear to be “robust” |
| Bakhtiary et al. [18] (2008), Germany | 1/2003–11/2006 | 45 patients: -CABG (n = 20) -LVAD (n = 5) -OHT (n = 1) -CABG & Post-infarction VSD (n = 3) -CABG & MV repair (n = 5) -AVR (n = 2) -CABG & AVR (n = 3) -Miscellaneous (n = 5) |
Average age: 60.1 years +/− 13.6 Weaned from ECMO: 55% (n = 25) 30-day mortality: 55% (n = 25) In-hospital morality: 71% (n = 32) Survival to hospital discharge: 29% (n = 13) 3-year survival: 77% (n = 10) with NYHA class II (n = 6), NYHA class IV (n = 4) Improved survival: absence of pulmonary hypertension and use of IABP (p = 0.04) |
Authors concluded that VA-ECMO provides sufficient cardiopulmonary support. Peripheral cannulation techniques and reduced anticoagulation could reduce bleeding rates |
| Doll et al. [8] (2003), Germany | 11/1997–02/2000 | 95 patients: -CABG (n = 63) -AVR (n = 16) -CABG & AVR (n = 8) -Others (n = 8) |
Average age: 59.8 years +/− 13.3 Weaned from ECMO: 47% (n = 45) Survival to hospital discharge: 29% (n = 28) Mortality rates for CABG & AVR on ECMO: 100% (p < 0.05) Complications: renal failure (64%), re-exploration for haemorrhage (62%), & limb ischaemia (16%) |
Authors concluded that “short term” ECMO support is a suitable technique for short-term low cardiac out states |
| Wang et al. [43] (1996), Taiwan | 10/1994–10/1995 | 18 patients: -CABG (N = 7) -CABG & Valve (n = 3) -OHT (n = 3) -Valve (n = 2) -Miscellaneous (n = 3) |
Average age: 46.5 years +/− 24.6 Weaned from ECMO: 52.6% (n = 10) Survival to hospital discharge: 33% (n = 6) in “good condition” Complications: leg ischaemia (n = 3), bleeding (n = 4), renal failure (n = 3), and tube rupture (n = 1) |
One patient received 2 runs of ECMO This cohort included routine adult cardiac surgery as well as heart transplants |
| Magovern et al. [44] (1994), USA | 10/1991–10/1993 | 21 patients Divided into 3 categories: -Cat 1: after CABG (n = 14) -Cat 2: MV surgery (n = 3) -Cat 3: after open heart surgery & prolonged CPR (n = 4) |
Mean age: 61.6 years +/− 2.2 (33–78) Survival to hospital discharge: -Cat 1: 80% (0% for both categories 2 & 3) -Total survival to hospital discharge: 52% Complications: stroke, renal failure, and mediastinitis |
Authors commented that VA-ECMO in the context of MV surgery does not decompress the LV (where there is often concurrent LV distension), thus is not effective |
| Saxena et al. [45] (2015), USA | 2003–2013 | 45 patients Additional inclusion criteria: age > 70 years: -Valve repair/replacement (n = 16) -Valve & CABG (n = 13) -Other (n = 16) |
Mean age: 76.8 years +/− 4.6 Mortality whilst on ECMO: 46.6% (n = 21) Weaned from ECMO: 53.3% (n = 24) Survival to hospital discharge: 24% (n = 11) Complications: renal failure 44.4% (n = 30), pneumonia 26.7% [12], & sepsis 24.4% (n = 11) Adverse prognostic indicators: preoperative AF, CKD, lactic acidosis on ECMO, persistent coagulopathy |
Total 47 runs of ECMO (two patients each received two runs) Authors concluded that VA-ECMO for PCCS confers high morbidity & mortality rates. However, it provides a last line of support for patients that would otherwise die |
| Li et al. [15] (2015), China | 01/2011–12/2012 | 123 patients: -CABG (n = 44) -CABG & other (n = 15) -Valve (n = 40) -OHT (n = 11) -Other (n = 13) |
Mean age: 56.2 years +/− 11.8 (range 18–76) Weaned from ECMO: 56% Survival to hospital discharge: 34.1% |
Predictors of in-hospital mortality: advanced age, female sex, elevated mean lactate and lactate clearance (p < 0.05) |
| Yan et al. [46] (2010), China | 2004–2008 | 67 patients: -CABG +/− Valve (n = 49) -OHT (n = 9) -Adult CHD (n = 5) -Other (n = 5) |
Average age: 50.5 years +/− 13.6 Survival to hospital discharge: 49% Prognostic indicators: mortality was much higher amongst patients who received RRT than those that did not (73% vs 32%, p = 0.001) |
Authors concluded that renal failure is a major ECMO-related complication after PPCS and is associated with a significant mortality rate |
Abbreviations: ECMO Extra-corporeal membrane oxygenator, CABG coronary artery bypass grafting, IABP Intra-aortic balloon pump, LVAD Left ventricular assist device, RVAD Right ventricular assist device, BiVAD Biventricular assist device, NYHA New York Heart Association, MODS Multi-organ dysfunction syndrome, VA veno-arterial, GI gastrointestinal, AVR aortic valve replacement, MVR Mitral valve replacement, CI cardiac index, CPB Cardiopulmonary bypass, AS aortic stenosis, MI Myocardial infarction, LMS left main stem coronary artery, PVD peripheral vascular disease
PCCS Post cardiotomy cardiogenic shock, ICU intensive care unit, LV left ventricle, RV right ventricle, RRT renal replacement therapy, Pts patients, OHT orthotopic heart transplantation, CHD congenital heart disease, MV mitral valve, MVR mitral valve replacement, TV tricuspid valve, TVR tricuspid valve replacement