Division of Cardiovascular Surgery, Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea.
Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea.
Eur J Cardiothorac Surg. 2021 Dec 1;60(6):1318-1324. doi: 10.1093/ejcts/ezab339.
Patient selection is crucial to improving the outcomes of extracorporeal cardiopulmonary resuscitation (ECPR). However, ECPR's efficacy with older patients remains unknown.
We reviewed patients who underwent extracorporeal membrane oxygenation (ECMO) for refractory cardiac arrest from January 2006 to December 2018. Exclusion criteria were age <18 years, cannulation failure and ECMO applied at another hospital. We divided patients into 2 groups with an age cut-off of 66 years, using the Contal and O'Quigley method for overall survival. We performed inverse probability of treatment weighting (IPTW) between the 2 groups and set the primary outcome as overall survival.
We included 318 patients in our study (≤66 years, n = 199; >66 years, n = 119). Before IPTW, we observed that the older group had a higher frequency of diabetes, hypertension, and myocardial infarction. In the young group, more patients had out-of-hospital cardiac arrest as compared with the older group. The hospital mortality rate was 55% (48.7% in the young group, 65.5% in the older group; P = 0.004). In the multivariable analysis after IPTW, the older group showed worse outcomes in overall survival [hazard ratio (HR) = 2.02; 95% confidence interval (CI), 1.50-2.70; P < 0.001] and neurological outcomes at discharge (odds ratio = 2.95; 95% CI, 1.69-5.14; P = <0.001). ECMO insertion during catheterization (HR = 0.57; 95% CI, 0.36-0.90; P = 0.015) and recovery of spontaneous circulation before pump-on (HR = 0.67; 95% CI, 0.50-0.89; P = 0.007) were positive predictors, but initial asystole rhythm, non-cardiac cause (HR = 2.39; 95% CI, 1.59-3.61; P < 0.001), out-of-hospital cardiac arrest (HR = 1.86; 95% CI, 1.24-2.79; P = 0.003) and prolonged cardiopulmonary resuscitation to pump-on time (HR = 1.01; 95% CI, 1.01-1.02; P < 0.001) were negative predictors for overall survival.
Older patients who had ECPR had significantly worse survival and neurological outcomes. For patients older than age 66 years, more careful patient selection is critically important for improving the efficacy of ECPR.
患者选择对于提高体外心肺复苏（ECPR）的效果至关重要。然而，ECPR 对老年患者的疗效仍不清楚。
我们回顾了 2006 年 1 月至 2018 年 12 月期间因难治性心脏骤停接受体外膜氧合（ECMO）治疗的患者。排除标准为年龄<18 岁、置管失败和 ECMO 在其他医院应用。我们使用 Contal 和 O'Quigley 方法将患者分为两组，以 66 岁为年龄截断值，用于总体生存率。我们在两组之间进行了逆概率治疗加权（IPTW），并将总体生存率作为主要结局。
我们的研究纳入了 318 名患者（≤66 岁，n=199；>66 岁，n=119）。在进行 IPTW 之前，我们观察到老年组糖尿病、高血压和心肌梗死的发生率较高。在年轻组中，更多的患者发生院外心脏骤停。院内死亡率为 55%（年轻组为 48.7%，老年组为 65.5%；P=0.004）。在 IPTW 后的多变量分析中，老年组在总体生存率（风险比[HR]=2.02；95%置信区间[CI]，1.50-2.70；P<0.001）和出院时的神经结局（比值比=2.95；95%CI，1.69-5.14；P=0.001）方面表现更差。导管插入期间的 ECMO 插入（HR=0.57；95%CI，0.36-0.90；P=0.015）和泵前自主循环恢复（HR=0.67；95%CI，0.50-0.89；P=0.007）是阳性预测因素，而初始停搏节律、非心脏原因（HR=2.39；95%CI，1.59-3.61；P<0.001）、院外心脏骤停（HR=1.86；95%CI，1.24-2.79；P=0.003）和心肺复苏到泵上时间延长（HR=1.01；95%CI，1.01-1.02；P<0.001）是总体生存率的负预测因素。
接受 ECPR 的老年患者的生存率和神经结局明显较差。对于年龄大于 66 岁的患者，更仔细的患者选择对于提高 ECPR 的疗效至关重要。
