On-Support and Postweaning Mortality in Postcardiotomy Extracorporeal Membrane Oxygenation

Silvia Mariani*, Anne Kristin Schaefer, PELS Investigators, Bas C.T. van Bussel, Michele Di Mauro, Luca Conci, Philipp Szalkiewicz, Maria Elena De Piero, Samuel Heuts, Justine Ravaux, Iwan C.C. van der Horst, Diyar Saeed, Matteo Pozzi, Antonio Loforte, Udo Boeken, Robertas Samalavicius, Karl Bounader, Xiaotong Hou, Jeroen J.H. Bunge, Hergen BuscherLeonardo Salazar, Bart Meyns, Daniel Herr, Sacha Matteucci, Sandro Sponga, Graeme MacLaren, Claudio Russo, Francesco Formica, Pranya Sakiyalak, Antonio Fiore, Daniele Camboni, Giuseppe Maria Raffa, Rodrigo Diaz, I. wen Wang, Jae Seung Jung, Jan Belohlavek, Vin Pellegrino, Giacomo Bianchi, Matteo Pettinari, Alessandro Barbone, José P. Garcia, Glenn Whitman, Kiran Shekar, Dominik Wiedemann, Roberto Lorusso, Jawad Khalil, Sven Lehmann, Jean Francois Obadia, Nikolaos Kalampokas, Erwan Flecher, Dinis Dos Reis Miranda

*Corresponding author for this work

Research output: Contribution to journalArticleAcademicpeer-review

1 Citation (Scopus)

Abstract

Background: 

Postcardiotomy venoarterial extracorporeal membrane oxygenation (VA ECMO) is characterized by discrepancies between weaning and survival-to-discharge rates. This study analyzes the differences between postcardiotomy VA ECMO patients who survived, died on ECMO, or died after ECMO weaning. Causes of death and variables associated with mortality at different time points are investigated.

Methods: 

The retrospective, multicenter, observational Postcardiotomy Extracorporeal Life Support Study (PELS) includes adults requiring postcardiotomy VA ECMO between 2000 and 2020. Variables associated with on-ECMO mortality and postweaning mortality were modeled using mixed Cox proportional hazards, including random effects for center and year. 

Results: 

In 2058 patients (men, 59%; median age, 65 years; interquartile range [IQR], 55-72 years), weaning rate was 62.7%, and survival to discharge was 39.6%. Patients who died (n = 1244) included 754 on-ECMO deaths (36.6%; median support time, 79 hours; IQR, 24-192 hours), and 476 postweaning deaths (23.1%; median support time, 146 hours; IQR, 96-235.5 hours). Multiorgan (n = 431 of 1158 [37.2%]) and persistent heart failure (n = 423 of 1158 [36.5%]) were the main causes of death, followed by bleeding (n = 56 of 754 [7.4%]) for on-ECMO mortality and sepsis (n = 61 of 401 [15.4%]) for postweaning mortality. On-ECMO death was associated with emergency surgery, preoperative cardiac arrest, cardiogenic shock, right ventricular failure, cardiopulmonary bypass time, and ECMO implantation timing. Diabetes, postoperative bleeding, cardiac arrest, bowel ischemia, acute kidney injury, and septic shock were associated with postweaning mortality. 

Conclusions: 

A discrepancy exists between weaning and discharge rate in postcardiotomy ECMO. Deaths occurred during ECMO support in 36.6% of patients, mostly associated with unstable preoperative hemodynamics. Another 23.1% of patients died after weaning in association with severe complications. This underscores the importance of postweaning care for postcardiotomy VA ECMO patients.

Original languageEnglish
Pages (from-to)1079-1089
Number of pages11
JournalAnnals of Thoracic Surgery
Volume116
Issue number5
Early online date5 Jul 2023
DOIs
Publication statusPublished - Nov 2023

Bibliographical note

Funding Information:
List of PELS Investigators: Jawad Khalil, PhD,1 Sven Lehmann, PhD,1 Jean-Francois Obadia, PhD,2 Nikolaos Kalampokas, MD,3 Erwan Flecher, PhD,4 Dinis Dos Reis Miranda, PhD,5,6 Kogulan Sriranjan, MD,7 Michael A Mazzeffi, MD, MPH,8,9 Nazli Vedadi, MD,8,9 Marco Di Eusanio, PhD,10 Vitaly Sorokin, PhD,11 Kollengode Ramanathan, MD,11 Alessandro Costetti, MD,12 Chistof Schmid, PhD,13 Roberto Castillo, MD,14 Vladimir Mikulenka, MD, MBA,15 and Marco Solinas, MD16, 1Department of Cardiac Surgery, Leipzig Heart Center, Leipzig, Germany; 2Department of Cardiac Surgery, Louis Pradel Cardiologic Hospital, Lyon, France; 3Department of Cardiac Surgery, Medical Faculty, Heinrich Heine University, Duesseldorf, Germany; 4Division of Cardiothoracic and Vascular Surgery, Pontchaillou University Hospital, Rennes, France; 5Department of Intensive Care Adults, Erasmus MC, Rotterdam, the Netherlands; 6Department of Cardiology, Erasmus MC, Rotterdam, the Netherlands; 7Department of Intensive Care Medicine, Center of Applied Medical Research, St Vincent's Hospital, Darlinghurst, New South Wales, Australia; 8Department of Medicine, University of Maryland, Baltimore, Maryland; 9Department of Surgery, University of Maryland, Baltimore, Maryland; 10Struttura Organizzativa Dipartimentale Cardiochirurgia Ospedali Riuniti ‘Umberto I - Lancisi - Salesi’ Università Politecnica delle Marche, Ancona, Italy; 11Cardiothoracic Intensive Care Unit, National University Heart Centre, National University Hospital, Singapore, Singapore; 12Cardiac Surgery Unit, Cardiac Thoracic and Vascular Department, Niguarda Hospital, Milan, Italy; 13Department of Cardiothoracic Surgery, University Medical Center Regensburg, Regensburg, Germany; 14ECMO Unit, Departamento de Anestesia, Clínica Las Condes, Las Condes, Santiago, Chile; 15Second Department of Internal Medicine, Cardiovascular Medicine General Teaching Hospital, First Faculty of Medicine, Charles University in Prague, Prague, Czech Republic; and 16Ospedale del Cuore Fondazione Toscana “G. Monasterio,” Massa, Italy, The authors have no funding sources to disclose. Roberto Lorusso receives honoraria paid as research funding from Xenios, reports consulting or advisory relationships with Medtronic, Getinge AB, AbioMed, and LivaNova, and is an advisory board member of Eurosets, HemoCue AB, and Xenios AG. Dominik Wiedemann is a consultant/proctor with Abbott and reports a consulting or advisory relationship with Xenios AG. Kogulan Ramanathan reports a consulting or advisory relationship with Baxter and Fresenius Kabi AG and reports honorarium from Baxter and Fresenius for educational lectures not related to this topic. The other authors have no conflicts of interest to disclose.

Publisher Copyright:
© 2023 The Society of Thoracic Surgeons

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