Percutaneous versus surgical femoro-femoral veno-arterial ECMO: a propensity score matched study

To assess the outcomes and long-term quality-of-life of patients supported by extracorporeal membrane oxygenation (ECMO) for refractory cardiogenic shock. Refractory cardiogenic shock is almost always lethal without emergency circulatory support, e.g., ECMO. ECMO-associated morbidity and mortality plead for identification of early predictors of its failure, and detailed analyses of short- and long-term outcomes to refine patient selection and improve results. Outcomes of 81 patients given ECMO support for medical (n = 55), postcardiotomy (n = 16), or posttransplantation (n = 10) cardiogenic shock were evaluated. Thirty-four (42%) patients survived to hospital discharge; 57% suffered > or = 1 major ECMO-related complications. Independent predictors of intensive care unit death were: device insertion under cardiac massage (odds ratio [OR] = 20.68), 24 hr urine output < 500 mL (OR = 6.52), prothrombin activity < 50% (OR = 3.93), and female sex (OR = 3.89); myocarditides were associated with better outcomes (OR = .13). Sequelae and health-related quality-of-life were evaluated for 28 long-term survivors (median follow-up, 11 months), whose mean Short-Form 36 scores were significantly lower than matched healthy controls for physical role, general health, and social functioning, but higher than those reported for patients on chronic hemodialysis, with advanced heart failure, or after recovery from acute respiratory distress syndrome. ECMO support can rescue 40% of otherwise fatal cardiogenic shock patients but its initiation under cardiac massage or after renal or hepatic failure carried higher risks of intensive care unit death, while fulminant myocarditis had a better prognosis. Despite satisfactory mental health and vitality, long-term survivors' persistent physical and social problems might benefit from tailored medical or psychosocial interventions.

This study was designed to identify factors associated with in-intensive care unit (ICU) death and develop a practical mortality risk score for venoarterial-extracorporeal membrane oxygenation (VA-ECMO)-treated acute myocardial infarction (AMI) patients. Long-term survivors' health-related quality of life (HRQOL), anxiety, depression, and post-traumatic stress disorder (PTSD) frequencies were also assessed.

Incidence and impact on adult patients' outcomes of nosocomial infections (NIs) occurring during venoarterial extracorporeal membrane oxygenation (VA-ECMO) support for refractory cardiogenic shock have rarely been described. We retrospectively reviewed the charts of a large series of patients who received VA-ECMO in our intensive care unit (ICU) from January 2003 through December 2009. Incidence, types, risk factors, and impact on outcomes of NIs occurring during ECMO support were analyzed. Among 220 patients (49 ± 16 years old, simplified acute physiology score (SAPS) II 61 ± 20) who underwent ECMO support for >48 hours for a total of 2942 ECMO days, 142 (64%) developed NIs. Ventilator-associated pneumonia (VAP), bloodstream infections, cannula infections, and mediastinitis infections occurred in 55%, 18%, 10% and 11% of the patients, respectively. More critical condition at ICU admission, but not antibiotics at the time of ECMO cannulation, was associated with subsequently developing NIs (hazard ratio, 0.73; 95% confidence interval [CI], .50-1.05; P = .09). Infected patients had longer durations of mechanical ventilation, ECMO support, and hospital stays. Independent predictors of death were infection with severe sepsis or septic shock (odds ratio, 1.93; 95% CI, 1.26-2.94; P = .002) and SAPS II, whereas immunosuppression and myocarditis as the reason for ECMO support were associated with better outcomes. Cardiogenic shock patients who received the latest generation VA-ECMO still had a high risk of developing NIs, particularly VAP. Strategies aimed at preventing these infections may improve the outcomes of these critically ill patients.