Using extracorporeal life support to resuscitate adult postcardiotomy cardiogenic shock: Treatment strategies and predictors of short-term and midterm survival

doi:10.1016/j.resuscitation.2010.04.031

Resuscitation

Volume 81, Issue 9, September 2010, Pages 1111-1116

https://doi.org/10.1016/j.resuscitation.2010.04.031 Get rights and content

Abstract

Background

Postcardiotomy extracorporeal life support (ECLS) is a resource-demanding therapy with varied results among institutions. An organized protocol was necessary to improve the effectiveness of this therapy.

Methods and results

A total of 110 patients received ECLS due to refractory postcardiotomy cardiogenic shock between January 2003 and June 2009, and were eligible for inclusion in this retrospective study. Preoperative, perioperative, and postoperative variables were collected, including the European system for cardiac operative risk evaluation (EuroSCORE) and markers of ECLS-related organ injuries. All variables were analyzed for possible associations with mortality in hospital, and after hospital discharge. The mean age, additive EuroSCORE, and left ventricular ejection fraction (LVEF) for all patients was 60 (±14) years, 9 (±6), and 43% (±20%) respectively. Sixty-seven patients were weaned from ECLS and 46 survived to hospital discharge. The mean duration of ECLS support was 143 h (±112 h). Multivariate analysis revealed that an age of >60 years, a necessity for postoperative continuous arteriovenous hemofiltration, a maximal serum total bilirubin >6 mg/dL, and a need for ECLS support for >110 h were independent predictors of in-hospital mortality. In addition, persistent heart failure with LVEF <30% was an independent predictor of mortality after hospital discharge. A risk-predicting score for in-hospital mortality associated with postcardiotomy ECLS was developed for clinical application.

Conclusion

Based on the abovementioned findings, a comprehensive protocol for postcardiotomy ECLS was designed. The primary objective was to achieve adequate hemodynamics within the first 24 h of initiating ECLS. Other objectives of the protocol included a consistent approach to safe anticoagulation while on ECLS, a process to make decisions within 7 days of initiating ECLS, and patient follow-up after hospital discharge.

Introduction

Extracorporeal life support (ECLS) is an effective but short-term treatment for severe acute heart failure. Postcardiotomy ECLS may be necessary in order to bridge some adults with severe acute heart failure to recovery or heart transplantation (HT).1, 2, 3, 4 It is often difficult to predict the duration of ECLS support that will be necessary to achieve these endpoints.5, 6 The use of ECLS for this purpose is attractive due to its relative simplicity and inexpensiveness, and its ability to provide biventricular support. In general, 30% of adults supported with ECLS postoperatively are weaned from ECLS within 3–5 days.2, 4 Institutions that use ECLS as a rescue therapy for adults with refractory heart failure need clear treatment protocols with defined therapeutic targets. Within such a protocol, the strategy of ‘bridging to recovery’ can be altered to ‘bridge to transplant’ for those patients that fail to improve. In order to create such a protocol and to improve our clinical outcomes, we reviewed our experience over a 6-year period with adult postcardiotomy ECLS.

Section snippets

Materials and methods

Between January 2003 and June 2009, a total of 4180 patients underwent cardiac surgery in our institution. Of these patients, 114 patients required ECLS due to failure to be weaned from cardiopulmonary bypass (CPB) (n = 102) or a refractory cardiogenic shock after cardiac operation (n = 12). Only patients who received venoarterial ECLS for cardiac support (n = 110) were included in this retrospective study. Patients who received venovenous ECLS to treat postoperative pulmonary dysfunction (n = 4) were

Patient characteristics

The operations performed included: isolated coronary artery bypass grafting (CABG; n = 31), single valve surgery (n = 16), multiple valve procedures (n = 26), CABG combined with valve or left ventricular volume reduction surgery (n = 19), aortic root replacement with or without ascending aortic surgery (n = 8), postinfarction ventricular septal defect (n = 3), pulmonary endarterectomy (n = 4), and HT (n = 3). Sixty percent of the patients were successfully weaned from ECLS (67/110), and 41.8% (46/110) of them

Discussion

This study aimed to clarify the efficacy and limitations of postcardiotomy ECLS in adult patients. In the current study, nearly 50% of patients in this “crash and burn” category¹¹ recovered after temporary ECLS support. However, postcardiotomy ECLS is inappropriate for patients with a high likelihood of irreversible cardiac damage unless consideration is given to bridging to HT. In this study, elective cardiac surgical patients with a preoperative LVEF < 30% that required postcardiotomy ECLS were

Limitations

The limitations of this study are the moderate number of study patients and its retrospective design. Refining surgical techniques and increasing experience with VADs and HT are necessary to improve our results. Further prospective research into postcardiotomy ECLS, both laboratory and clinical, are required to improve our therapeutic protocol.

Conclusion

Postcardiotomy ECLS is an effective but temporary measure. A comprehensive protocol that integrates VAD and HT is essential for institutions that apply ECLS as a rescue therapy for patients with severe acute heart failure. Monitoring after hospital discharge is also an important part of such a protocol, especially in patients with severe heart failure.

Conflict of interest statement

None to declare.

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^☆: A Spanish translated version of the abstract of this article appears as Appendix in the final online version at doi:10.1016/j.resuscitation.2010.04.031.

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Clinical paperUsing extracorporeal life support to resuscitate adult postcardiotomy cardiogenic shock: Treatment strategies and predictors of short-term and midterm survival☆

Abstract

Background

Methods and results

Conclusion

Introduction

Section snippets

Materials and methods

Patient characteristics

Discussion

Limitations

Conclusion

Conflict of interest statement

Ann Thorac Surg

Ann Thorac Surg

J Thorac Cardiovasc Surg

Ann Thorac Surg

Resuscitation

J Pediatr Surg

Am J Transplant

Clinical paper
Using extracorporeal life support to resuscitate adult postcardiotomy cardiogenic shock: Treatment strategies and predictors of short-term and midterm survival☆