Elsevier

The Annals of Thoracic Surgery

Volume 92, Issue 6, December 2011, Pages 2125-2131
The Annals of Thoracic Surgery

Original article
Adult cardiac
Extracorporeal Membrane Oxygenation for Advanced Refractory Shock in Acute and Chronic Cardiomyopathy

https://doi.org/10.1016/j.athoracsur.2011.07.029Get rights and content

Background

Extracorporeal membrane oxygenation (ECMO) has been used to obtain rapid resuscitation and stabilization in advanced refractory cardiogenic shock (CS), but clear strategies to optimize outcomes and minimize futile support have not been established.

Methods

We retrospectively reviewed our experience with ECMO in patients with advanced refractory CS, after an acute myocardial infarct (AMI) compared with patients receiving ECMO after an acute decompensating chronic cardiomyopathy (CCM).

Results

Between January 2003 and February 2009, 33 patients required ECMO support for advanced refractory CS secondary to AMI (AMI-CS) and 9 patients were supported by ECMO in the presence of an acutely decompensated CCM (CCM-CS). Survival at 30 days, 1 and 2 years for patients with AMI-CS, was 64%, 48%, and 48% compared with 56%, 11%, and 11% at the same time points for those with CCM-CS (p = 0.05). In the AMI-CS group, 14 of 33 (42%) patients were weaned directly from ECMO after revascularization; 15 of 33 (45%) patients were bridged to ventricular assist device (VAD) support and subsequently either underwent heart transplantation (n = 6), were successfully weaned from VAD (n = 2) or died while on VAD support (n = 7). In the CCM-CS group, 7 patients were bridged to VAD support (77%), with 1 patient surviving after VAD weaning.

Conclusions

Extracorporeal membrane oxygenation in advanced refractory AMI-CS is associated with acceptable outcomes in a well-selected population. The ECMO in patients with an acute decompensation of a chronic CM should be carefully considered, to avoid futile support.

Section snippets

Study Protocol

Between January 2003 and February 2009, 42 patients required the use of ECMO support at the UPMC (University of Pittsburgh Medical Center). In 33 patients, the primary cause of CS was a confirmed AMI, while in the other 9 patients the etiology was an acutely decompensated CCM (7 dilated and 2 ischemic) in the absence of an acute coronary event, as assessed by electrocardiographic, enzymatic, or angiographic criteria. Data were obtained from the UPMC transplant and mechanical support database

Results

Demographic and clinical characteristics of the patients in both groups are presented in Table 1. Patients with CCM-CS had higher creatinine, bilirubin, and blood lactate levels at the time of initiation of ECMO support than patients with AMI-CS. Twenty-seven patients with AMI-CS (27 of 33; 82%) underwent an initial PCI attempt prior to or simultaneously with ECMO implantation. Revascularization was possible in 21 patients receiving ECMO for AMI-CS, by PCI alone (13 patients), CABG alone (3

Comment

In this study, we report a single-center experience with the use of ECMO to stabilize patients with advanced refractory CS secondary to an AMI and unresponsive to medical management, including considerations for patient selection, implantation, and subsequent management. We found that ECMO provided effective support in patients after an AMI complicated by advanced refractory CS as a bridge to recovery or to a more durable support (VAD) while waiting for a heart transplant. Mechanical support in

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