Prognostic Implication of Pre-Cannulation Cardiac Arrest in Patients Undergoing Extracorporeal Membrane Oxygenation for the Management of Cardiogenic Shock

Abstract

Background

The application of veno-arterial extracorporeal membrane oxygenation (VA-ECMO) in contemporary management of cardiogenic shock (CS) has dramatically increased. Despite increased utilization, few predictive models exist to estimate patient survival based on pre-ECMO characteristics. Furthermore, the prognostic implications of pre-ECMO cardiac arrest are not well defined.

Methods

Utilizing an institutional VA-ECMO database, all consecutive patients undergoing VA-ECMO for the management of CS from January 1, 2014, to July 1, 2019, were identified. Survival to hospital discharge was analyzed based on cannulation indication in patients with and without pre-ECMO cardiac arrest. Patients who received extracorporeal cardiopulmonary resuscitation (eCPR) were analyzed separately.

Results

Of the 214 patients identified, 110 did not suffer a cardiac arrest prior to cannulation (cohort 1), 57 patients had a cardiac arrest with sustained ROSC (cohort 2), and 47 were cannulated as a component of eCPR (cohort 3). Despite sustained ROSC (cohort 2), the presence of pre-ECMO cardiac arrest was associated with a significant reduction in survival to hospital discharge (22.8% vs. 55.5% in cohort 1; p < 0.001). Comparatively, survival to discharge was similar in patients undergoing eCPR (22.8% vs. 17.0%; p = 0.464). Finally, patients with a cardiac arrest were significantly more likely to have a neurological etiology death with VA-ECMO than patients supported prior to hemodynamic collapse (18.3% vs. 2.7%; p < 0.001). This result is seen in those with sustained ROSC (21.1% vs. 2.7%; p < 0.001) and those with eCPR (14.9% vs. 2.7%; p = 0.004).

Conclusion

In our cohort, pre-ECMO cardiac arrest carries a negative prognostic value across all indications and is associated with an increased prevalence of neurological-etiology death. This finding is true in patients with sustained ROSC as well as those resuscitated with eCPR. Cardiac arrest can inform survival probability with VA-ECMO as early implementation of VA-ECMO may mitigate adverse outcomes in patients at the highest risk of hemodynamic collapse.

Keywords

ECMO cardiac arrest shock outcome assessment

Get full access to this article

View all access options for this article.

References

Stretch

Sauer

Yuh

Bonde

. National trends in the utilization of short-term mechanical circulatory support: incidence, outcomes, and cost analysis. J Am Coll Cardiol. 2014;64(14):1407‐1415.

Eckman

Katz

El Banayosy

Bohula

Sun

van Diepen

. Veno-Arterial extracorporeal membrane oxygenation for cardiogenic shock: an introduction for the busy clinician. Circulation. 2019;140(24):2019‐2037.

Guglin

Zucker

Bazan

, et al. Venoarterial ECMO for adults: JACC scientific expert panel. J Am Coll Cardiol. 2019;73(6):698‐716.

Rao

Khalpey

Smith

Burkhoff

Kociol

. Venoarterial extracorporeal membrane oxygenation for cardiogenic shock and cardiac arrest. Circ Heart Fail. 2018;11(9):e004905.

McCarthy

McDermott

Kini

, et al. Trends in U.S. extracorporeal membrane oxygenation use and outcomes: 2002–2012. Semin Thorac Cardiovasc Surg. 2015;27(2):81‐88.

Thiagarajan

Brogan

Scheurer

Laussen

Rycus

Bratton

. Extracorporeal membrane oxygenation to support cardiopulmonary resuscitation in adults. Ann Thorac Surg. 2009;87(3):778‐785.

Link

Berkow

Kudenchuk

, et al. Part 7: adult advanced cardiovascular life support: 2015 American heart association guidelines update for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation. 2015;132(18 Suppl 2):S444‐S464.

Bascom

Dziodzio

Vasaiwala

, et al. Derivation and validation of the CREST model for very early prediction of circulatory etiology death in patients without ST-Segment-Elevation myocardial infarction after cardiac arrest. Circulation. 2018;137(3):273‐282.

Chiu

Pillado

Sareh

De La Cruz

Shemin

Benharash

. Financial and clinical outcomes of extracorporeal mechanical support. J Card Surg. 2017;32(3):215‐221.

10.

Oude Lansink-Hartgring

van den Hengel

van der Bij

, et al. Hospital costs of extracorporeal life support therapy. Crit Care Med. 2016;44(4):717‐723.

11.

Marasco

Vale

Pellegrino

, et al. Extracorporeal membrane oxygenation in primary graft failure after heart transplantation. Ann Thorac Surg. 2010;90(5):1541‐1546.

12.

Schmidt

Burrell

Roberts

, et al. Predicting survival after ECMO for refractory cardiogenic shock: the survival after veno-arterial-ECMO (SAVE)-score. Eur Heart J. 2015;36(33):2246‐2256.

13.

Rajan

Wissenberg

Folke

, et al. Association of bystander cardiopulmonary resuscitation and survival according to ambulance response times after out-of-hospital cardiac arrest. Circulation. 2016;134(25):2095‐2104.

14.

Kagawa

Inoue

Kawagoe

, et al. Assessment of outcomes and differences between in- and out-of-hospital cardiac arrest patients treated with cardiopulmonary resuscitation using extracorporeal life support. Resuscitation. 2010;81(8):968‐973.

15.

Reynolds

Frisch

Rittenberger

Callaway

. Duration of resuscitation efforts and functional outcome after out-of-hospital cardiac arrest: when should we change to novel therapies? Circulation. 2013;128(23):2488‐2494.

16.

Kim

Jung

Park

Hong

Lee

. An optimal transition time to extracorporeal cardiopulmonary resuscitation for predicting good neurological outcome in patients with out-of-hospital cardiac arrest: a propensity-matched study. Crit Care. 2014;18(5):535.