Whiteside Hoyle L, Hillerson Dustin, Abdel-Latif Ahmed, Gupta Vedant A
Gill Heart & Vascular Institute, 4530University of Kentucky, Lexington, KY, USA.
Division of Cardiovascular Medicine, 5232University of Wisconsin-Madison, Madison, WI, USA.
J Intensive Care Med. 2023 Feb;38(2):202-207. doi: 10.1177/08850666221115606. Epub 2022 Jul 19.
The application of veno-arterial extracorporeal membrane oxygenation (VA-ECMO) in contemporary management of cardiogenic shock (CS) has dramatically increased. Despite increased utilization, few predictive models exist to estimate patient survival based on pre-ECMO characteristics. Furthermore, the prognostic implications of pre-ECMO cardiac arrest are not well defined.
Utilizing an institutional VA-ECMO database, all consecutive patients undergoing VA-ECMO for the management of CS from January 1, 2014, to July 1, 2019, were identified. Survival to hospital discharge was analyzed based on cannulation indication in patients with and without pre-ECMO cardiac arrest. Patients who received extracorporeal cardiopulmonary resuscitation (eCPR) were analyzed separately.
Of the 214 patients identified, 110 did not suffer a cardiac arrest prior to cannulation (cohort 1), 57 patients had a cardiac arrest with sustained ROSC (cohort 2), and 47 were cannulated as a component of eCPR (cohort 3). Despite sustained ROSC (cohort 2), the presence of pre-ECMO cardiac arrest was associated with a significant reduction in survival to hospital discharge (22.8% vs. 55.5% in cohort 1; p < 0.001). Comparatively, survival to discharge was similar in patients undergoing eCPR (22.8% vs. 17.0%; p = 0.464). Finally, patients with a cardiac arrest were significantly more likely to have a neurological etiology death with VA-ECMO than patients supported prior to hemodynamic collapse (18.3% vs. 2.7%; p < 0.001). This result is seen in those with sustained ROSC (21.1% vs. 2.7%; p < 0.001) and those with eCPR (14.9% vs. 2.7%; p = 0.004).
In our cohort, pre-ECMO cardiac arrest carries a negative prognostic value across all indications and is associated with an increased prevalence of neurological-etiology death. This finding is true in patients with sustained ROSC as well as those resuscitated with eCPR. Cardiac arrest can inform survival probability with VA-ECMO as early implementation of VA-ECMO may mitigate adverse outcomes in patients at the highest risk of hemodynamic collapse.
在当代心源性休克（CS）的治疗中，静脉-动脉体外膜肺氧合（VA-ECMO）的应用显著增加。尽管其使用增多，但基于体外膜肺氧合（ECMO）前特征来估计患者生存情况的预测模型却很少。此外，ECMO前心脏骤停的预后意义尚不明确。
利用一个机构的VA-ECMO数据库，确定了2014年1月1日至2019年7月1日期间所有因CS接受VA-ECMO治疗的连续患者。根据插管指征，对有或无ECMO前心脏骤停的患者出院生存率进行分析。接受体外心肺复苏（eCPR）的患者单独进行分析。
在确定的214例患者中，110例在插管前未发生心脏骤停（队列1），57例心脏骤停后恢复自主循环（ROSC）（队列2），47例作为eCPR的一部分进行插管（队列3）。尽管恢复了自主循环（队列2），但ECMO前心脏骤停与出院生存率显著降低相关（队列1中为22.8% vs. 55.5%；p<0.001）。相比之下，接受eCPR的患者出院生存率相似（22.8% vs. 17.0%；p = 0.464）。最后，与血流动力学崩溃前接受支持的患者相比，心脏骤停患者接受VA-ECMO时因神经系统病因死亡的可能性显著更高（18.3% vs. 2.7%；p<0.001）。在恢复自主循环的患者（21.1% vs. 2.7%；p<0.001）和接受eCPR的患者（14.9% vs. 2.7%；p = 0.004）中均可见此结果。
在我们的队列中，ECMO前心脏骤停在所有指征中均具有负面预后价值，且与神经系统病因死亡的患病率增加相关。这一发现在恢复自主循环的患者以及接受eCPR复苏的患者中均成立。心脏骤停可提示VA-ECMO的生存概率，因为早期实施VA-ECMO可能减轻血流动力学崩溃风险最高患者的不良结局。
