Early and late outcomes of 517 consecutive adult patients treated with extracorporeal membrane oxygenation for refractory postcardiotomy cardiogenic shock

Objective

Adult postcardiotomy cardiogenic shock potentially requiring mechanical circulatory support occurs in 0.5% to 1.5% of cases. Risk factors influencing early or long-term outcome after extracorporeal membrane oxygenation implantation are not well described.

Methods

Between May 1996 and May 2008, 517 adult patients received extracorporeal membrane oxygenation support for postcardiotomy cardiogenic shock. Procedures were isolated coronary artery bypass grafting (37.4%), isolated valve surgery (14.3%), coronary artery bypass grafting plus valve surgery (16.8%), thoracic organ transplantion (6.5%), and other combinations (25.0%). Fifty-four preoperative and 42 procedural risk factors concerning in-hospital mortality were evaluated by logistic regression analyses.

Results

Mean age was 63.5 years, 71.5% were male, ejection fraction was 45.9% ± 17.6%, logistic EuroSCORE was 21.6% ± 20.7%. Extracorporeal membrane oxygenation was established through thoracic (60.8%) or extrathoracic (39.2%) cannulation. Extracorporeal membrane oxygenation support was 3.28 ± 2.85 days. Intra-aortic balloon pumps were implanted in 74.1%. Weaning from extracorporeal membrane oxygenation was successful for 63.3%, and 24.8% were discharged. Cerebrovascular events occurred in 17.4%, gastrointestinal complications in 18.8%, and renal replacement therapy in 65.0%. Risk factors for hospital mortality were age older than 70 years (odds ratio, 1.6), diabetes (odds ratio, 2.5), preoperative renal insufficiency (odds ratio, 2.1), obesity (odds ratio, 1.8), logistic EuroSCORE greater than 20% (odds ratio, 1.8), operative lactate greater than 4 mmol/L (odds ratio, 2.2). Isolated coronary artery bypass grafting (odds ratio, 0.44) was protective. Cumulative survivals were 17.6% after 6 months, 16.5% after 1 year, and 13.7% after 5 years.

Conclusions

Extracorporeal membrane oxygenation support is an acceptable option for patients with postcardiotomy cardiogenic shock who otherwise would die and is justified by good long-term outcome of hospital survivors. Because of high morbidity and mortality, extracorporeal membrane oxygenation must be decided by individual risk profile.

CTSNet classification: 25.1, 27, 30

Abbreviations and Acronyms: ECMO, extracorporeal membrane oxygenation, IABP, intra-aortic balloon pump, OR, odds ratio, PCS, postcardiotomy cardiogenic shock, L-VAD, left ventricular assist device