Duration of veno-arterial extracorporeal life support (VA ECMO) and outcome: an analysis of the Extracorporeal Life Support Organization (ELSO) registry

Myles Smith, Alexander Vukomanovic, Daniel Brodie, Ravi Thiagarajan, Peter Rycus, Hergen Buscher, Myles Smith, Alexander Vukomanovic, Daniel Brodie, Ravi Thiagarajan, Peter Rycus, Hergen Buscher

Abstract

Background: Veno-arterial extracorporeal membrane oxygenation (VA ECMO) is an effective rescue therapy for severe cardiorespiratory failure, but morbidity and mortality are high. We hypothesised that survival decreases with longer VA ECMO treatment. We examined the Extracorporeal Life Support Organization (ELSO) registry for a relationship between VA ECMO duration and in-hospital mortality, and covariates including indication for support.

Methods: All VA runs from the ELSO database from 2002 to 2012 were extracted. Multiple runs and non-VA runs were excluded. Runs were categorized into diagnostic groups. Logistic regression for analysis of the effect of duration on outcome, and multivariate regression for diagnosis and other baseline factors were performed. Non-linear models including piecewise logistic models were fitted.

Results: There were 2699 runs analysed over 14,747 days. Logistic regression analysis of the effect of duration on outcome, and multivariate regression analysis of diagnosis and other baseline factors were performed. In-hospital survival was 41.4% (95% CI 39.6-43.3). 75% of patients were supported for less than 1 week and 96% for less than 3 weeks. Median duration (4 days IQR 2.0-6.8) was greater in survivors (4.1 (IQR 2.5-6.7) vs 3.8 (IQR 1.7-7.0) p = 0.002). The final multivariate model demonstrated increasing survival to day 4 (OR 1.53 (95% CI 1.37-1.71) p < 0.001), decreasing from day 4 to 12 (OR 0.86 (95% CI 0.81-0.91), p < 0.001) with no significant change thereafter (OR 0.98 (95% CI 0.94-1.02), p = 0.400).

Conclusions: ECMO for 4 days or less is associated with higher mortality, likely reflecting early treatment failure. Survival is highest when patients are weaned on the fourth day of ECMO but likely decreases into the second week. While this does not suggest weaning at this point will produce better outcomes, it does reflect the likely time course of ECMO as a bridge in severe shock. Patients with some underlying conditions (like myocarditis and heart transplantation) achieve better outcomes despite longer support duration. These findings merit prospective study for the development of prognostic models and weaning strategies.

Keywords: Extracorporeal Life Support Organization; Extracorporeal membrane oxygenation; Outcomes; Refractory shock; Survival; Treatment duration.

Figures

Fig. 1
Fig. 1
Trends in survival and diagnosis by year of extracorporeal membrane oxygenation (ECMO) treatment. a Survival by year of ECMO treatment, with total number of patients treated that year, and 95% confidence intervals for survival. b Diagnostic groups by year of ECMO treatment. VAD ventricular assist device
Fig. 2
Fig. 2
Survival by day of extracorporeal membrane oxygenation (ECMO) discontinuation. Errors bars show 95% binomial confidence interval for survival
Fig. 3
Fig. 3
Estimated survival hazard in the first 4 weeks, with cumulative incidence of survival and mortality. Coloured curves show cumulative incidence of survival after cessation of extracorporeal membrane oxygenation (ECMO) (green), and mortality after ECMO (red), by duration of treatment. Instantaneous hazard function estimate for survival plotted in black with 95% confidence interval. Numbers of patients at risk and who survived or died are shown per week below the chart
Fig. 4
Fig. 4
Reasons for discontinuation and death by extracorporeal membrane oxygentation (ECMO) duration. Reasons for discontinuation of ECMO, and death according to ECMO duration are presented. Colour of bars indicates reason for discontinuation (red organ failure, green family request, blue diagnosis incompatible with life, purple haemorrhage). Overall outcomes and reasons for discontinuation are summarised

References

    1. Xie A, Phan K, Tsai Y-C, Yan TD, Forrest P. Venoarterial extracorporeal membrane oxygenation for cardiogenic shock and cardiac arrest: a meta-analysis. J Cardiothorac Vasc Anesth. 2015;29:637–45. doi: 10.1053/j.jvca.2014.09.005.
    1. Extracorporeal Life Support Organization - ECMO and ECLS > Registry > Statistics > International Summary. 2016. . Accessed 6 May 2016.
    1. Schmidt M, Burrell A, Roberts L, Bailey M, Sheldrake J, Rycus PT, et al. Predicting survival after ECMO for refractory cardiogenic shock: the survival after veno-arterial-ECMO (SAVE)-score. Eur Heart J. 2015;36:2246–56. doi: 10.1093/eurheartj/ehv194.
    1. Morimoto Y, Sugimoto T, Shiozawa H. Long-term extracorporeal membrane oxygenator support in resuscitation for intractable hibernating myocardium after coronary artery bypass grafting. Ann Thorac Cardiovasc Surg. 2011;17:611–3. doi: 10.5761/atcs.cr.10.01625.
    1. Aubron C, Cheng AC, Pilcher D, Leong T, Magrin G, Cooper DJ, et al. Factors associated with outcomes of patients on extracorporeal membrane oxygenation support: a 5-year cohort study. Crit Care. 2013;17:R73. doi: 10.1186/cc12681.
    1. Camboni D, Philipp A, Lubnow M, Bein T, Haneya A, Diez C, et al. Support time-dependent outcome analysis for veno-venous extracorporeal membrane oxygenation. Eur J Cardiothorac Surg. 2011;40:1341–7.
    1. Staudacher DL, Bode C, Wengenmayer T. Duration of extracorporeal membrane oxygenation is a poor predictor of hospital survival. J Crit Care. 2016;32:207–8. doi: 10.1016/j.jcrc.2016.01.001.
    1. Gupta P, Robertson MJ, Beam B, Gossett JM, Schmitz ML, Carroll CL, et al. Relationship of ECMO duration with outcomes after pediatric cardiac surgery: a multi-institutional analysis. Minerva Anestesiol. 2015;81:619–27.
    1. Merrill ED, Schoeneberg L, Sandesara P, Molitor-Kirsch E, O’Brien J, Dai H, et al. Outcomes after prolonged extracorporeal membrane oxygenation support in children with cardiac disease–Extracorporeal Life Support Organization registry study. J Thorac Cardiovasc Surg. 2014;148:582–8. doi: 10.1016/j.jtcvs.2013.09.038.
    1. Schmidt M, Bréchot N, Hariri S, Guiguet M, Luyt CE, Makri R, et al. Nosocomial infections in adult cardiogenic shock patients supported by venoarterial extracorporeal membrane oxygenation. Clin Infect Dis. 2012;55:1633–41. doi: 10.1093/cid/cis783.
    1. Teixeira L, Rodrigues A, Carvalho MJ, Cabrita A, Mendonça D. Modelling competing risks in nephrology research: an example in peritoneal dialysis. BMC Nephrol. 2013;14:110. doi: 10.1186/1471-2369-14-110.
    1. Muggeo VMR. Estimating regression models with unknown break-points. Stat Med. 2003;22:3055–71. doi: 10.1002/sim.1545.
    1. Gray B. cmprsk: subdistribution analysis of competing risks. 2014. . Accessed 6 May 2016.
    1. Zangrillo A, Landoni G, Biondi-Zoccai G, Greco M, Greco T, Frati G, et al. A meta-analysis of complications and mortality of extracorporeal membrane oxygenation. Crit Care Resusc. 2013;15:172–8.
    1. Smith A, Hardison D, Bridges B, Pietsch J. Red blood cell transfusion volume and mortality among patients receiving extracorporeal membrane oxygenation. Perfusion. 2013;28:54–60. doi: 10.1177/0267659112457969.
    1. Posluszny J, Rycus PT, Bartlett RH, Engoren M, Haft JW, Lynch WR, et al. Outcome of adult respiratory failure patients receiving prolonged (≥14 days) ECMO. Ann Surg. 2016;263:573–81. doi: 10.1097/SLA.0000000000001176.
    1. Omar HR, Mirsaeidi M, Mangar D, Camporesi EM. Duration of ECMO is an independent predictor of intracranial hemorrhage occurring during ECMO support. ASAIO J. 2016;62:634–6. doi: 10.1097/MAT.0000000000000368.
    1. Tsai M-T, Hsu C-H, Luo C-Y, Hu Y-N, Roan J-N. Bridge-to-recovery strategy using extracorporeal membrane oxygenation for critical pulmonary hypertension complicated with cardiogenic shock. Interact Cardiovasc Thorac Surg. 2015;21:55–61. doi: 10.1093/icvts/ivv070.
    1. Haibo Z, Xu M, Jie H, Yixin J. Planned extracorporeal membrane oxygenation technique for peri-transplantation support for heart allografts with known prolonged ischemic time. J Heart Lung Transplant. 2010;29:133–4. doi: 10.1016/j.healun.2009.08.013.
    1. Park TK, Yang JH, Jeon K, Choi S-H, Choi J-H, Gwon H-C, et al. Extracorporeal membrane oxygenation for refractory septic shock in adults. Eur J Cardiothorac Surg. 2015;47:e68–74. doi: 10.1093/ejcts/ezu462.
    1. Huang C-T, Tsai Y-J, Tsai P-R, Ko W-J. Extracorporeal membrane oxygenation resuscitation in adult patients with refractory septic shock. J Thorac Cardiovasc Surg. 2013;146:1041–6. doi: 10.1016/j.jtcvs.2012.08.022.
    1. Bréchot N, Luyt C-E, Schmidt M, Leprince P, Trouillet J-L, Léger P, et al. Venoarterial extracorporeal membrane oxygenation support for refractory cardiovascular dysfunction during severe bacterial septic shock. Crit Care Med. 2013;41:1616–26. doi: 10.1097/CCM.0b013e31828a2370.
    1. Firstenberg MS, Abel E, Blais D, Louis LB, Steinberg S, Sai-Sudhakar C, et al. The use of extracorporeal membrane oxygenation in severe necrotizing soft tissue infections complicated by septic shock. Am Surg. 2010;76:1287–9.
    1. Javidfar J, Brodie D, Costa J, Miller J, Jurrado J, LaVelle M, et al. Subclavian artery cannulation for venoarterial extracorporeal membrane oxygenation. ASAIO J. 2012;58:494–8. doi: 10.1097/MAT.0b013e318268ea15.
    1. Gray BW, Haft JW, Hirsch JC, Annich GM, Hirschl RB, Bartlett RH. Extracorporeal life support: experience with 2000 patients. ASAIO J. 2015;61:2–7. doi: 10.1097/MAT.0000000000000150.
    1. Karagiannidis C, Brodie D, Strassmann S, Stoelben E, Philipp A, Bein T, et al. Extracorporeal membrane oxygenation: evolving epidemiology and mortality. Intensive Care Med. 2016;42:889–96. doi: 10.1007/s00134-016-4273-z.
    1. Quintel M, Gattinoni L, Weber-Carstens S. The German ECMO inflation: when things other than health and care begin to rule medicine. Intensive Care Med. 2016;42:1264–6. doi: 10.1007/s00134-016-4380-x.
    1. Nakamura T, Ishida K, Taniguchi Y, Nakagawa T, Seguchi M, Wada H, et al. Prognosis of patients with fulminant myocarditis managed by peripheral venoarterial extracorporeal membranous oxygenation support: a retrospective single-center study. J Intensive Care. 2015;3:5. doi: 10.1186/s40560-014-0069-9.
    1. Mody KP, Takayama H, Landes E, Yuzefpolskaya M, Colombo PC, Naka Y, et al. Acute mechanical circulatory support for fulminant myocarditis complicated by cardiogenic shock. J Cardiovasc Transl Res. 2014;7:156–64. doi: 10.1007/s12265-013-9521-9.
    1. Lorusso R, Centofanti P, Gelsomino S, Barili F, Di Mauro M, Orlando P, et al. Venoarterial extracorporeal membrane oxygenation for acute fulminant myocarditis in adult patients: a 5-year multi-institutional experience. Ann Thorac Surg. 2016;101:919–26. doi: 10.1016/j.athoracsur.2015.08.014.
    1. Listijono DR, Watson A, Pye R, Keogh AM, Kotlyar E, Spratt P, et al. Usefulness of extracorporeal membrane oxygenation for early cardiac allograft dysfunction. J Heart Lung Transplant. 2011;30:783–9. doi: 10.1016/j.healun.2011.01.728.
    1. Lehmann S, Uhlemann M, Etz CD, Garbade J, Schroeter T, Borger M, et al. Extracorporeal membrane oxygenation: experience in acute graft failure after heart transplantation. Clin Transplant. 2014;28:789–96. doi: 10.1111/ctr.12380.
    1. Leprince P, Aubert S, Bonnet N, Rama A, Léger P, Bors V, et al. Peripheral extracorporeal membrane oxygenation (ECMO) in patients with posttransplant cardiac graft failure. Transplant Proc. 2005;37:2879–80. doi: 10.1016/j.transproceed.2005.05.018.
    1. Gupta P, McDonald R, Chipman CW, Stroud M, Gossett JM, Imamura M, et al. 20-year experience of prolonged extracorporeal membrane oxygenation in critically ill children with cardiac or pulmonary failure. Ann Thorac Surg. 2012;93:1584–90. doi: 10.1016/j.athoracsur.2012.01.008.

Source: PubMed

Sponsor e collaboratori

Condizioni mediche

Interventi farmacologici

3
Sottoscrivi