Fux Thomas, Holm Manne, Corbascio Matthias, Lund Lars H, van der Linden Jan
Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden.
Division of Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden.
Artif Organs. 2019 Feb;43(2):132-141. doi: 10.1111/aor.13331. Epub 2018 Nov 6.
Refractory cardiogenic shock (RCS) is associated with a high mortality. Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is increasingly used as acute cardiopulmonary support but selection of VA-ECMO candidates remains challenging. There are limited data on which pre-VA-ECMO variables that predict outcome. The aim of this study was to identify pre-VA-ECMO predictors of 90-day mortality. We retrospectively analyzed 76 consecutive patients (median age 52; interquartile range [IQR]: 37-60) supported with VA-ECMO due to RCS. The association between pre-implant variables and all-cause mortality at 90 days was analyzed with multivariable logistic regression. Main etiologies of RCS were acute myocardial infarction 51% and other AHF etiologies 49%. Cardiopulmonary resuscitation was performed in 54% of patients before initiation of VA-ECMO. Median duration of VA-ECMO was 5 days (IQR: 2-11). The 90-day overall mortality was 49% and in-hospital mortality was 50%; 46% died on VA-ECMO, 37% were successfully weaned, 13% were bridged to heart transplantation, and 4% to left ventricular assist device. Multivariable logistic regression analysis identified arterial lactate (odds ratio [OR] per mmol/L: 1.15; 95% confidence interval [CI]: 1.06-1.24; P = 0.001) and number of inotropes and vasopressors (OR per agent: 2.14; 95% CI: 1.26-3.63; P = 0.005) as independent predictors of 90-day mortality. In RCS patients arterial lactate level and number of inotropes and vasopressors were identified as independent pre-VA-ECMO predictors of 90-day mortality. Thus, the severity of cardiogenic shock expressed as levels of lactate and vasoactive agents just before start of VA-ECMO may be more predictive of outcome than the specific etiology of cardiogenic shock.
难治性心源性休克（RCS）与高死亡率相关。静脉-动脉体外膜肺氧合（VA-ECMO）越来越多地被用作急性心肺支持，但VA-ECMO候选者的选择仍然具有挑战性。关于哪些VA-ECMO前变量可预测预后的数据有限。本研究的目的是确定VA-ECMO前90天死亡率的预测因素。我们回顾性分析了76例因RCS接受VA-ECMO支持的连续患者（中位年龄52岁；四分位间距[IQR]：37-60岁）。采用多变量逻辑回归分析植入前变量与90天全因死亡率之间的关联。RCS的主要病因是急性心肌梗死占51%，其他急性心力衰竭病因占49%。54%的患者在开始VA-ECMO前进行了心肺复苏。VA-ECMO的中位持续时间为5天（IQR：2-11天）。90天总死亡率为49%，住院死亡率为50%；46%死于VA-ECMO，37%成功撤机，13%过渡到心脏移植，4%过渡到左心室辅助装置。多变量逻辑回归分析确定动脉血乳酸（每毫摩尔/升比值比[OR]：1.15；95%置信区间[CI]：1.06-1.24；P = 0.001）以及血管活性药物的数量（每种药物的OR：2.14；95%CI：1.26-3.63；P = 0.005）是90天死亡率的独立预测因素。在RCS患者中，动脉血乳酸水平以及血管活性药物的数量被确定为VA-ECMO前90天死亡率的独立预测因素。因此，在开始VA-ECMO之前以乳酸和血管活性药物水平表示的心源性休克严重程度可能比心源性休克的具体病因更能预测预后。
