Time course, factors related to, and prognostic impact of venoarterial extracorporeal membrane flow in cardiogenic shock
Por:
Montero, S, Rivas-Lasarte, M, Huang, F, Chommeloux, J, Demondion, P, Brechot, N, Hekimian, G, Franchineau, G, Persichini, R, Luyt, CE, Garcia-Garcia, C, Bayes-Genis, A, Lebreton, G, Cinca, J, Leprince, P, Combes, A, Alvarez-Garcia, J and Schmidt, M
Publicada:
1 feb 2023
Ahead of Print:
1 nov 2022
Resumen:
Aims Venoarterial extracorporeal membrane oxygenation (VA-ECMO) is currently one of the most used devices in refractory cardiogenic shock. However, there is a lack of evidence on how to set the 'optimal' flow. We aimed to describe the evolution of VA-ECMO flows in a cardiogenic shock population and determine the risk factors of 'high-ECMO flow'.
Methods and results A 7 year database of patients supported with VA-ECMO was used. Based on the median flow during the first 48 h of the VA-ECMO run, patients were classified as 'high-flow' or 'low-flow', respectively, when median ECMO flow was >= 3.6 or <3.6 L/min. Outcomes included rates of ventilator-associated pneumonia, ECMO-related complications, days on ECMO, days on mechanical ventilation, intensive care unit and hospitalization lengths of stay, and in-hospital and 60 day mortality. Risk factors of high-ECMO flow were assessed using univariate and multivariate cox regression. The study population included 209 patients on VA-ECMO, median age was 51 (40-59) years, and 78% were males. The most frequent aetiology leading to cardiogenic shock was end-stage dilated cardiomyopathy (57%), followed by acute myocardial infarction (23%) and fulminant myocarditis (17%). Among the 209 patients, 105 (50%) were classified as 'high-flow'. This group had a higher rate of ischaemic aetiology (16% vs. 30%, P = 0.023) and was sicker at admission, in terms of worse Simplified Acute Physiology Score II score [40 (26-58) vs. 56 (42-74), P < 0.001], higher lactate [3.6 (2.2-5.8) mmol/L vs. 5.2 (3-9.7) mmol/L, P < 0.001], and higher aspartate aminotransferase [97 (41-375) U/L vs. 309 (85-939) U/L, P < 0.001], among others. The 'low-flow' group had less ventilator-associated pneumonia (40% vs. 59%, P = 0.007) and less days on mechanical ventilation [4 (1.5-7.5) vs. 6 (3-12) days, P = 0.009]. No differences were found in lengths of stay or survival according to the ECMO flow. The multivariate analysis showed that risk factors independently associated with 'high-flow' were mechanical ventilation at cannulation [odds ratio (OR) 3.9, 95% confidence interval (CI) 2.1-7.1] and pre-ECMO lactate (OR 1.1, 95% CI 1.0-1.2).
Conclusions In patients with refractory cardiogenic shock supported with VA-ECMO, sicker patients had higher support since early phases, presenting thereafter higher rates of ventilator-associated pneumonia but similar survival compared with patients with lower flows.
Filiaciones:
:
Univ Autonoma Barcelona, Hosp Germans Trias & Pujol, Dept Med, Cardiol,Acute Cardiovasc Care Unit, Barcelona, Spain
Hop La Pitie Salpetriere, AP HP, Med Intens Care Unit, Paris 13, France
Rivas-Lasarte, M:
Hosp Univ Puerta Hierro Majadahonda, Cardiol Dept, Adv Heart Failure & Heart Transplant Unit, CIBERCV, Madrid, Spain
Huang, F:
Hop La Pitie Salpetriere, AP HP, Med Intens Care Unit, Paris 13, France
Chommeloux, J:
Hop La Pitie Salpetriere, AP HP, Med Intens Care Unit, Paris 13, France
Demondion, P:
Hop La Pitie Salpetriere, AP HP, Thorac & Cardiovasc Dept, Paris 13, France
Sorbonne Univ, Inst Cardiometab & Nutr, INSERM UMRS 1166 ICAN, F-75651 Paris 13, France
Brechot, N:
Hop La Pitie Salpetriere, AP HP, Med Intens Care Unit, Paris 13, France
Sorbonne Univ, Inst Cardiometab & Nutr, INSERM UMRS 1166 ICAN, F-75651 Paris 13, France
Hekimian, G:
Hop La Pitie Salpetriere, AP HP, Med Intens Care Unit, Paris 13, France
Sorbonne Univ, Inst Cardiometab & Nutr, INSERM UMRS 1166 ICAN, F-75651 Paris 13, France
Franchineau, G:
Hop La Pitie Salpetriere, AP HP, Med Intens Care Unit, Paris 13, France
Sorbonne Univ, Inst Cardiometab & Nutr, INSERM UMRS 1166 ICAN, F-75651 Paris 13, France
Persichini, R:
Felix Guyon Hosp, Med Surg Intens Care Unit, CHU La Reunion, St Denis, La Reunion, France
Luyt, CE:
Hop La Pitie Salpetriere, AP HP, Med Intens Care Unit, Paris 13, France
Sorbonne Univ, Inst Cardiometab & Nutr, INSERM UMRS 1166 ICAN, F-75651 Paris 13, France
:
Univ Autonoma Barcelona, Hosp Germans Trias & Pujol, Dept Med, Cardiol,Acute Cardiovasc Care Unit, Barcelona, Spain
:
Univ Autonoma Barcelona, Hosp Germans Trias & Pujol, Dept Med, Cardiol,Acute Cardiovasc Care Unit, Barcelona, Spain
Lebreton, G:
Hop La Pitie Salpetriere, AP HP, Thorac & Cardiovasc Dept, Paris 13, France
Sorbonne Univ, Inst Cardiometab & Nutr, INSERM UMRS 1166 ICAN, F-75651 Paris 13, France
Cinca, J:
Univ Autonoma Barcelona, Cardiol Dept, Hosp La Santa Creu & St Pau, Barcelona, Spain
Leprince, P:
Hop La Pitie Salpetriere, AP HP, Thorac & Cardiovasc Dept, Paris 13, France
Sorbonne Univ, Inst Cardiometab & Nutr, INSERM UMRS 1166 ICAN, F-75651 Paris 13, France
Combes, A:
Hop La Pitie Salpetriere, AP HP, Med Intens Care Unit, Paris 13, France
Sorbonne Univ, Inst Cardiometab & Nutr, INSERM UMRS 1166 ICAN, F-75651 Paris 13, France
Alvarez-Garcia, J:
Hosp Ramon & Cajal, Ctr Invest Red Enfermedades Cardiovasc CIBERCV, Cardiol Dept, Madrid, Spain
Schmidt, M:
Hop La Pitie Salpetriere, AP HP, Med Intens Care Unit, Paris 13, France
Sorbonne Univ, Inst Cardiometab & Nutr, INSERM UMRS 1166 ICAN, F-75651 Paris 13, France
Green Published, gold
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