Predictors of successful extracorporeal membrane oxygenation (ECMO) weaning after assistance for refractory cardiogenic shock
- 3k Downloads
Detailed extracorporeal membrane oxygenation (ECMO) weaning strategies and specific predictors of ECMO weaning success are lacking. This study evaluated a weaning strategy following support for refractory cardiogenic shock to identify clinical, hemodynamic, and Doppler echocardiography parameters associated with successful ECMO removal.
Hemodynamically stable patients underwent ECMO flow reduction trials to <1.5 L/min under clinical and Doppler echocardiography monitoring. When a patient had partially or fully recovered from severe cardiac dysfunction, tolerated the weaning trial, and had left ventricular ejection fraction (LVEF) >20–25% and aortic time–velocity integral (VTI) >10 cm under minimal ECMO support, device removal was considered.
Among the 51 patients (34 males, aged 54 ± 14 years) who received ECMO for medical (n = 27), postcardiotomy (n = 11), or posttransplantation (n = 5) cardiogenic shock, 38 tolerated at least one ECMO flow reduction trial and 20 were ultimately weaned. Compared with the 13 patients who tolerated the trial but were not deemed weanable, those successfully weaned had, at each ECMO flow level, higher arterial systolic and pulse pressures, VTI, LVEF, and lateral mitral annulus peak systolic velocity (TDSa). All weaned patients had aortic VTI ≥10 cm, LVEF >20–25%, and TDSa ≥6 cm/s at minimal ECMO flow support. These Doppler echocardiography parameters better separated weaned and nonweaned patients than any other parameters tested.
Patients who tolerated a full ECMO weaning trial and had aortic VTI ≥10 cm, LVEF >20–25%, and TDSa ≥6 cm/s at minimal ECMO flow were all successfully weaned. However, further studies are needed to validate these simple and easy-to-acquire Doppler echocardiography parameters as predictors of subsequent ECMO weaning success in patients recovering from severe cardiogenic shock.
KeywordsExtracorporeal membrane oxygenation Salvage therapy Cardiogenic shock Outcome predictors Doppler echocardiography
- 2.Chen YS, Lin JW, Yu HY, Ko WJ, Jerng JS, Chang WT, Chen WJ, Huang SC, Chi NH, Wang CH, Chen LC, Tsai PR, Wang SS, Hwang JJ, Lin FY (2008) Cardiopulmonary resuscitation with assisted extracorporeal life-support versus conventional cardiopulmonary resuscitation in adults with in-hospital cardiac arrest: an observational study and propensity analysis. Lancet 372:554–561PubMedCrossRefGoogle Scholar
- 3.Bakhtiary F, Keller H, Dogan S, Dzemali O, Oezaslan F, Meininger D, Ackermann H, Zwissler B, Kleine P, Moritz A (2008) Venoarterial extracorporeal membrane oxygenation for treatment of cardiogenic shock: clinical experiences in 45 adult patients. J Thorac Cardiovasc Surg 135:382–388PubMedCrossRefGoogle Scholar
- 6.Pagani FD, Lynch W, Swaniker F, Dyke DB, Bartlett R, Koelling T, Moscucci M, Deeb GM, Bolling S, Monaghan H, Aaronson KD (1999) Extracorporeal life support to left ventricular assist device bridge to heart transplant: a strategy to optimize survival and resource utilization. Circulation 100(19 Suppl):206–210Google Scholar
- 11.Chen JS, Ko WJ, Yu HY, Lai LP, Huang SC, Chi NH, Tsai CH, Wang SS, Lin FY, Chen YS (2006) Analysis of the outcome for patients experiencing myocardial infarction and cardiopulmonary resuscitation refractory to conventional therapies necessitating extracorporeal life support rescue. Crit Care Med 34:950–957PubMedCrossRefGoogle Scholar
- 12.Pages ON, Aubert S, Combes A, Luyt CE, Pavie A, Leger P, Gandjbakhch I, Leprince P (2009) Paracorporeal pulsatile biventricular assist device versus extracorporal membrane oxygenation-extracorporal life support in adult fulminant myocarditis. J Thorac Cardiovasc Surg 137:194–197PubMedCrossRefGoogle Scholar
- 13.Asaumi Y, Yasuda S, Morii I, Kakuchi H, Otsuka Y, Kawamura A, Sasako Y, Nakatani T, Nonogi H, Miyazaki S (2005) Favourable clinical outcome in patients with cardiogenic shock due to fulminant myocarditis supported by percutaneous extracorporeal membrane oxygenation. Eur Heart J 26:2185–2192PubMedCrossRefGoogle Scholar
- 14.Jan SL, Lin SJ, Fu YC, Chi CS, Wang CC, Wei HJ, Chang Y, Hwang B, Chen PY, Huang FL, Lin MC (2010) Extracorporeal life support for treatment of children with enterovirus 71 infection-related cardiopulmonary failure. Intensive Care Med 36:520–527Google Scholar
- 20.Vincent JL, Moreno R, Takala J, Willatts S, De Mendonca A, Bruining H, Reinhart CK, Suter PM, Thijs LG (1996) The SOFA (Sepsis-related Organ Failure Assessment) score to describe organ dysfunction/failure. On behalf of the Working Group on Sepsis-Related Problems of the European Society of Intensive Care Medicine. Intensive Care Med 22:707–710PubMedCrossRefGoogle Scholar
- 24.Park YS, Park JH, Ahn KT, Jang WI, Park HS, Kim JH, Lee JH, Choi SW, Jeong JO, Seong IW (2010) Usefulness of mitral annular systolic velocity in the detection of left ventricular systolic dysfunction: comparison with three dimensional echocardiographic data. J Cardiovasc Ultrasound 18:1–5PubMedCrossRefGoogle Scholar