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.
Data from 138 ECMO-treated AMI patients admitted to two French ICUs (2008–2013) were analyzed. ICU survivors contacted >6 months post-ICU discharge were assessed for HRQOL, psychological and PTSD status.
Sixty-five patients (47 %) survived to ICU discharge. On the basis of multivariable logistic regression analyses, the ENCOURAGE score was constructed with seven pre-ECMO parameters: age >60, female sex, body mass index >25 kg/m2, Glasgow coma score <6, creatinine >150 μmol/L, lactate (<2, 2–8, or >8 mmol/L), and prothrombin activity <50 %. Six months after ECMO, probabilities of survival were 80, 58, 25, 20, and 7 % for ENCOURAGE score classes 0–12, 13–18, 19–22, 23–27, and ≥28, respectively. The ENCOURAGE score ROC AUC [0.84 (95 % CI 0.77–0.91)] was significantly better than those of the SAVE, SAPS II, and SOFA scores. Survivors’ HRQOL evaluated after median follow-up of 32 months revealed satisfactory mental health but persistent physical and emotional-related difficulties, with 34 % (95 % CI 20–49 %) anxiety, 20 % (95 % CI 8–32 %) depression, and 5 % (95 % CI 0–12 %) PTSD symptoms reported.
The ENCOURAGE score might be a useful tool to predict mortality of severe cardiogenic shock AMI patients who received VA-ECMO. However, it now needs prospective validation on other populations of AMI patients.
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Thiele H, Ohman EM, Desch S, Eitel I, de Waha S (2015) Management of cardiogenic shock. Eur Heart J 36:1223–1230
Abrams D, Combes A, Brodie D (2014) Extracorporeal membrane oxygenation in cardiopulmonary disease in adults. J Am Coll Cardiol 63:2769–2778
Combes A, Leprince P, Luyt CE, Bonnet N, Trouillet JL, Leger P, Pavie A, Chastre J (2008) Outcomes and long-term quality-of-life of patients supported by extracorporeal membrane oxygenation for refractory cardiogenic shock. Crit Care Med 36:1404–1411
Petroni T, Harrois A, Amour J, Lebreton G, Brechot N, Tanaka S, Luyt CE, Trouillet JL, Chastre J, Leprince P, Duranteau J, Combes A (2014) Intra-aortic balloon pump effects on macrocirculation and microcirculation in cardiogenic shock patients supported by venoarterial extracorporeal membrane oxygenation. Crit Care Med 42:2075–2082
Brechot N, Luyt CE, Schmidt M, Leprince P, Trouillet JL, Leger P, Pavie A, Chastre J, Combes A (2013) Venoarterial extracorporeal membrane oxygenation support for refractory cardiovascular dysfunction during severe bacterial septic shock. Crit Care Med 41:1616–1626
Schmidt M, Brechot N, Hariri S, Guiguet M, Luyt CE, Makri R, Leprince P, Trouillet JL, Pavie A, Chastre J, Combes A (2012) Nosocomial infections in adult cardiogenic shock patients supported by venoarterial extracorporeal membrane oxygenation. Clin Infect Dis 55:1633–1641
Mirabel M, Luyt CE, Leprince P, Trouillet JL, Leger P, Pavie A, Chastre J, Combes A (2011) Outcomes, long-term quality of life, and psychologic assessment of fulminant myocarditis patients rescued by mechanical circulatory support. Crit Care Med 39:1029–1035
Doll N, Kiaii B, Borger M, Bucerius J, Kramer K, Schmitt DV, Walther T, Mohr FW (2004) Five-year results of 219 consecutive patients treated with extracorporeal membrane oxygenation for refractory postoperative cardiogenic shock. Ann Thorac Surg 77:151–157 (discussion 157)
Kim H, Lim SH, Hong J, Hong YS, Lee CJ, Jung JH, Yu S (2012) Efficacy of veno-arterial extracorporeal membrane oxygenation in acute myocardial infarction with cardiogenic shock. Resuscitation 83:971–975
Sheu JJ, Tsai TH, Lee FY, Fang HY, Sun CK, Leu S, Yang CH, Chen SM, Hang CL, Hsieh YK, Chen CJ, Wu CJ, Yip HK (2010) Early extracorporeal membrane oxygenator-assisted primary percutaneous coronary intervention improved 30-day clinical outcomes in patients with ST-segment elevation myocardial infarction complicated with profound cardiogenic shock. Crit Care Med 38:1810–1817
Schmidt M, Brechot N, Combes A (2015) Ten situations in which ECMO is unlikely to be successful. Intensive Care Med. doi:10.1007/s00134-015-4013-9
Windecker S, Kolh P, Alfonso F, Collet JP, Cremer J, Falk V, Filippatos G, Hamm C, Head SJ, Juni P, Kappetein AP, Kastrati A, Knuuti J, Landmesser U, Laufer G, Neumann FJ, Richter DJ, Schauerte P, Sousa Uva M, Stefanini GG, Taggart DP, Torracca L, Valgimigli M, Wijns W, Witkowski A (2014) 2014 ESC/EACTS guidelines on myocardial revascularization: the Task Force on Myocardial Revascularization of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS) developed with the special contribution of the European Association of Percutaneous Cardiovascular Interventions (EAPCI). Eur Heart J 35:2541–2619
Babaev A, Frederick PD, Pasta DJ, Every N, Sichrovsky T, Hochman JS (2005) Trends in management and outcomes of patients with acute myocardial infarction complicated by cardiogenic shock. JAMA 294:448–454
Klein LW, Shaw RE, Krone RJ, Brindis RG, Anderson HV, Block PC, McKay CR, Hewitt K, Weintraub WS (2005) Mortality after emergent percutaneous coronary intervention in cardiogenic shock secondary to acute myocardial infarction and usefulness of a mortality prediction model. Am J Cardiol 96:35–41
Sleeper LA, Reynolds HR, White HD, Webb JG, Dzavik V, Hochman JS (2010) A severity scoring system for risk assessment of patients with cardiogenic shock: a report from the SHOCK Trial and Registry. Am Heart J 160:443–450
Zeymer U, Vogt A, Zahn R, Weber MA, Tebbe U, Gottwik M, Bonzel T, Senges J, Neuhaus KL (2004) Predictors of in-hospital mortality in 1333 patients with acute myocardial infarction complicated by cardiogenic shock treated with primary percutaneous coronary intervention (PCI); results of the primary PCI registry of the Arbeitsgemeinschaft Leitende Kardiologische Krankenhausarzte (ALKK). Eur Heart J 25:322–328
Alexander JH, Reynolds HR, Stebbins AL, Dzavik V, Harrington RA, Van de Werf F, Hochman JS (2007) Effect of tilarginine acetate in patients with acute myocardial infarction and cardiogenic shock: the TRIUMPH randomized controlled trial. JAMA 297:1657–1666
Hochman JS, Sleeper LA, Webb JG, Dzavik V, Buller CE, Aylward P, Col J, White HD (2006) Early revascularization and long-term survival in cardiogenic shock complicating acute myocardial infarction. JAMA 295:2511–2515
Thiele H, Zeymer U, Neumann FJ, Ferenc M, Olbrich HG, Hausleiter J, Richardt G, Hennersdorf M, Empen K, Fuernau G, Desch S, Eitel I, Hambrecht R, Fuhrmann J, Bohm M, Ebelt H, Schneider S, Schuler G, Werdan K (2012) Intraaortic balloon support for myocardial infarction with cardiogenic shock. N Engl J Med 367:1287–1296
Schmidt M, Burrell A, Roberts L, Bailey M, Sheldrake J, Rycus PT, Hodgson C, Scheinkestel C, Cooper DJ, Thiagarajan RR, Brodie D, Pellegrino V, Pilcher D (2015) Predicting survival after ECMO for refractory cardiogenic shock: the survival after veno-arterial-ECMO (SAVE)-score. Eur Heart J 36:2246–2256
Leplege A, Ecosse E, Verdier A, Perneger TV (1998) The French SF-36 Health Survey: translation, cultural adaptation and preliminary psychometric evaluation. J Clin Epidemiol 51:1013–1023
Trouillet JL, Luyt CE, Guiguet M, Ouattara A, Vaissier E, Makri R, Nieszkowska A, Leprince P, Pavie A, Chastre J, Combes A (2011) Early percutaneous tracheotomy versus prolonged intubation of mechanically ventilated patients after cardiac surgery: a randomized trial. Ann Intern Med 154:373–383
Schmidt M, Zogheib E, Roze H, Repesse X, Lebreton G, Luyt CE, Trouillet JL, Brechot N, Nieszkowska A, Dupont H, Ouattara A, Leprince P, Chastre J, Combes A (2013) The PRESERVE mortality risk score and analysis of long-term outcomes after extracorporeal membrane oxygenation for severe acute respiratory distress syndrome. Intensive Care Med 39:1704–1713
Zigmond AS, Snaith RP (1983) The hospital anxiety and depression scale. Acta Psychiatr Scand 67:361–370
Horowitz M, Wilner N, Alvarez W (1979) Impact of event scale: a measure of subjective stress. Psychosom Med 41:209–218
Le Gall JR, Lemeshow S, Saulnier F (1993) A new Simplified Acute Physiology Score (SAPS II) based on a European/North American multicenter study. JAMA 270:2957–2963
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 22:707–710
Granger CB, Goldberg RJ, Dabbous O, Pieper KS, Eagle KA, Cannon CP, Van De Werf F, Avezum A, Goodman SG, Flather MD, Fox KA (2003) Predictors of hospital mortality in the global registry of acute coronary events. Arch Intern Med 163:2345–2353
Cheng JM, Helming AM, van Vark LC, Kardys I, Den Uil CA, Jewbali LS, van Geuns RJ, Zijlstra F, van Domburg RT, Boersma E, Akkerhuis KM (2015) A simple risk chart for initial risk assessment of 30-day mortality in patients with cardiogenic shock from ST-elevation myocardial infarction. Eur Heart J Acute Cardiovasc Care. doi:10.1177/2048872615568966
Sleeper LA, Ramanathan K, Picard MH, Lejemtel TH, White HD, Dzavik V, Tormey D, Avis NE, Hochman JS (2005) Functional status and quality of life after emergency revascularization for cardiogenic shock complicating acute myocardial infarction. J Am Coll Cardiol 46:266–273
Sanborn TA, Sleeper LA, Webb JG, French JK, Bergman G, Parikh M, Wong SC, Boland J, Pfisterer M, Slater JN, Sharma S, Hochman JS (2003) Correlates of one-year survival inpatients with cardiogenic shock complicating acute myocardial infarction: angiographic findings from the SHOCK trial. J Am Coll Cardiol 42:1373–1379
Distelmaier K, Winter MP, Rutzler K, Heinz G, Lang IM, Maurer G, Koinig H, Steinlechner B, Niessner A, Goliasch G (2014) Serum butyrylcholinesterase predicts survival after extracorporeal membrane oxygenation after cardiovascular surgery. Crit Care 18:R24
Kagawa E, Dote K, Kato M, Sasaki S, Nakano Y, Kajikawa M, Higashi A, Itakura K, Sera A, Inoue I, Kawagoe T, Ishihara M, Shimatani Y, Kurisu S (2012) Should we emergently revascularize occluded coronaries for cardiac arrest?: rapid-response extracorporeal membrane oxygenation and intra-arrest percutaneous coronary intervention. Circulation 126:1605–1613
Beurtheret S, Mordant P, Paoletti X, Marijon E, Celermajer DS, Leger P, Pavie A, Combes A, Leprince P (2013) Emergency circulatory support in refractory cardiogenic shock patients in remote institutions: a pilot study (the cardiac-RESCUE program). Eur Heart J 34:112–120
Ostenfeld S, Lindholm MG, Kjaergaard J, Bro-Jeppesen J, Moller JE, Wanscher M, Hassager C (2014) Prognostic implication of out-of-hospital cardiac arrest in patients with cardiogenic shock and acute myocardial infarction. Resuscitation 87C:57–62
Brown N, Melville M, Gray D, Young T, Munro J, Skene AM, Hampton JR (1999) Quality of life four years after acute myocardial infarction: short form 36 scores compared with a normal population. Heart 81:352–358
Kim J, Henderson RA, Pocock SJ, Clayton T, Sculpher MJ, Fox KA (2005) Health-related quality of life after interventional or conservative strategy in patients with unstable angina or non-ST-segment elevation myocardial infarction: one-year results of the third Randomized Intervention Trial of unstable Angina (RITA-3). J Am Coll Cardiol 45:221–228
Thiele H, Zeymer U, Neumann FJ, Ferenc M, Olbrich HG, Hausleiter J, de Waha A, Richardt G, Hennersdorf M, Empen K, Fuernau G, Desch S, Eitel I, Hambrecht R, Lauer B, Bohm M, Ebelt H, Schneider S, Werdan K, Schuler G (2013) Intra-aortic balloon counterpulsation in acute myocardial infarction complicated by cardiogenic shock (IABP-SHOCK II): final 12 month results of a randomised, open-label trial. Lancet 382:1638–1645
Herridge MS, Tansey CM, Matte A, Tomlinson G, Diaz-Granados N, Cooper A, Guest CB, Mazer CD, Mehta S, Stewart TE, Kudlow P, Cook D, Slutsky AS, Cheung AM (2011) Functional disability 5 years after acute respiratory distress syndrome. N Engl J Med 364:1293–1304
Martin CR, Lewin RJ, Thompson DR (2003) A confirmatory factor analysis of the Hospital Anxiety and Depression Scale in coronary care patients following acute myocardial infarction. Psychiatry Res 120:85–94
Ameratunga S, Tin Tin S, Coverdale J, Connor J, Norton R (2009) Posttraumatic stress among hospitalized and nonhospitalized survivors of serious car crashes: a population-based study. Psychiatr Serv 60:402–404
Edmondson D, Richardson S, Falzon L, Davidson KW, Mills MA, Neria Y (2012) Posttraumatic stress disorder prevalence and risk of recurrence in acute coronary syndrome patients: a meta-analytic review. PLoS One 7:e38915
Dickens CM, McGowan L, Percival C, Tomenson B, Cotter L, Heagerty A, Creed FH (2006) Contribution of depression and anxiety to impaired health-related quality of life following first myocardial infarction. Br J Psychiatry J Mental Sci 189:367–372
Luyt CE, Landivier A, Leprince P, Bernard M, Pavie A, Chastre J, Combes A (2012) Usefulness of cardiac biomarkers to predict cardiac recovery in patients on extracorporeal membrane oxygenation support for refractory cardiogenic shock. J Crit Care 27(524):e7–e14
Conflicts of interest
Dr. Combes is the primary investigator of the EOLIA trial, NCT01470703, a randomized trial of VV-ECMO supported in part by MAQUET. Dr. Combes has received honoraria for lectures from MAQUET.
Take-home message: The ENCOURAGE score proposed herein combines seven simple variables, readily available at pre-ECMO implantation, that might help physicians communicate objective prognostic information to surrogates, better select ECMO candidates among severe AMI patients, and might also be used to stratify inclusion of AMI-related cardiogenic shock patients in future randomized VA-ECMO studies. Long-term health-related quality of life was deemed satisfactory, although physical and emotional difficulties persisted in one-third of survivors.
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Muller, G., Flecher, E., Lebreton, G. et al. The ENCOURAGE mortality risk score and analysis of long-term outcomes after VA-ECMO for acute myocardial infarction with cardiogenic shock. Intensive Care Med 42, 370–378 (2016). https://doi.org/10.1007/s00134-016-4223-9
- Extracorporeal membrane oxygenation
- Acute myocardial infarction
- Cardiogenic shock
- Outcome assessment
- Long-term quality of life