Fadel Raef A, Almajed Mohamed Ramzi, Parsons Austin, Kalsi Jasmeet, Shadid Muthanna, Maki Mohamed, Alqarqaz Mohammad, Aronow Herb, Cowger Jennifer, Fuller Brittany, Frisoli Tiberio, Grafton Gillian, Kim Henry, Jones Crystal, Koenig Gerald, Khandelwal Akshay, Nemeh Hassan, O'Neill Brian, Tanaka Daizo, Williams Celeste, Villablanca Pedro, O'Neill William, Alaswad Khaldoon, Basir Mir Babar
Cardiovascular Medicine, Heart & Vascular Services, Henry Ford Hospital, Detroit, Michigan.
Department of Internal Medicine, Henry Ford Hospital, Detroit, Michigan.
J Soc Cardiovasc Angiogr Interv. 2024 Mar 22;3(6):101359. doi: 10.1016/j.jscai.2024.101359. eCollection 2024 Jun.
There has been a significant increase in the utilization of venoarterial extracorporeal membrane oxygenation (VA-ECMO) in recent years. Cardiothoracic surgery teams have historically led VA-ECMO care teams, with little data available on alternative care models.
We performed a retrospective review of a cardiovascular medicine inclusive VA-ECMO service, analyzing patients treated with peripheral VA-ECMO at a large quaternary care center from 2018 to 2022. The primary outcome was death while on VA-ECMO or within 24 hours of decannulation. Univariate and multivariate analyses were used to identify predictors of the primary outcome.
Two hundred forty-four patients were included in the analysis (median age 61 years; 28.7% female), of whom 91.8% were cannulated by interventional cardiologists, and 84.4% were managed by a cardiology service comprised of interventional cardiologists, cardiac intensivists or advanced heart failure cardiologists. Indications for VA-ECMO included acute myocardial infarction (34.8%), decompensated heart failure (30.3%), and refractory cardiac arrest (10.2%). VA-ECMO was utilized during cardiopulmonary resuscitation in 26.6% of cases, 48% of which were peri-procedural arrest. Of the patients, 46% survived to decannulation, the majority of whom were decannulated percutaneously in the cardiac catheterization laboratory. There was no difference in survival following cannulation by a cardiac surgeon vs interventional cardiologist (50% vs 45%; = .90). Complications included arterial injury (3.7%), compartment syndrome (4.1%), cannulation site infection (1.2%), stroke (14.8%), acute kidney injury (52.5%), access site bleeding (16%) and need for blood transfusion (83.2%). Elevated baseline lactate (odds ratio [OR], 1.13 per unit increase) and sequential organ failure assessment score (OR, 1.27 per unit increase) were independently associated with the primary outcome. Conversely, an elevated baseline survival after VA ECMO score (OR, 0.92 per unit increase) and 8-hour serum lactate clearance (OR, 0.98 per % increase) were independently associated with survival.
The use of a cardiovascular medicine inclusive ECMO service is feasible and may be practical in select centers as indications for VA-ECMO expand.
近年来，静脉-动脉体外膜肺氧合（VA-ECMO）的使用显著增加。历史上，心胸外科团队一直主导着VA-ECMO护理团队，关于替代护理模式的数据很少。
我们对一项包含心血管医学的VA-ECMO服务进行了回顾性研究，分析了2018年至2022年在一家大型四级护理中心接受外周VA-ECMO治疗的患者。主要结局是在VA-ECMO支持期间或拔管后24小时内死亡。采用单因素和多因素分析来确定主要结局的预测因素。
244例患者纳入分析（中位年龄61岁；28.7%为女性），其中91.8%由介入心脏病学家插管，84.4%由包括介入心脏病学家、心脏重症监护医生或晚期心力衰竭心脏病专家的心脏病服务团队管理。VA-ECMO的适应证包括急性心肌梗死（34.8%）、失代偿性心力衰竭（30.3%）和难治性心脏骤停（10.2%）。26.6%的病例在心肺复苏期间使用了VA-ECMO，其中48%为围手术期心脏骤停。患者中，46%存活至拔管，其中大多数在心脏导管室经皮拔管。心脏外科医生与介入心脏病学家插管后的生存率无差异（50%对45%；P = 0.90）。并发症包括动脉损伤（3.7%）、骨筋膜室综合征（4.1%）、插管部位感染（1.2%）、卒中（14.8%）、急性肾损伤（52.5%）、穿刺部位出血（16%）和输血需求（83.2%）。基线乳酸水平升高（比值比[OR]，每升高一个单位为1.13）和序贯器官衰竭评估评分升高（OR，每升高一个单位为1.27）与主要结局独立相关。相反，基线VA ECMO后生存评分升高（OR，每升高一个单位为0.92）和8小时血清乳酸清除率升高（OR，每升高1%为0.98）与生存独立相关。
随着VA-ECMO适应证的扩大，采用包含心血管医学的ECMO服务是可行的，在某些中心可能是切实可行的。
