Al Ghareeb Wael, Aldabbas Mohammad, Sheikh Ali Abdou, Al-Kassou Baravan, Gestrich Christopher, Nickenig Georg, Dewald Oliver, Mellert Fritz
Department of Cardiac Surgery, European Medical School Oldenburg-Groningen, Carl von Ossietzky University of Oldenburg, Oldenburg, DEU.
Department of Medicine II, Heart Center Bonn, University Hospital Bonn, Bonn, DEU.
Cureus. 2024 Sep 14;16(9):e69415. doi: 10.7759/cureus.69415. eCollection 2024 Sep.
Background Central venoarterial extracorporeal membrane oxygenation (VA-ECMO) is a commonly employed strategy to support patients in refractory postcardiotomy cardiogenic shock (RPCS). This support can be provided using either indirect central ECMO (icECMO) with a closed thorax or direct central ECMO (dcECMO) with an open thorax. Methods This single-center retrospective analysis included 60 patients undergoing central VA-ECMO for RPCS from January 2019 to December 2020. The primary endpoint of this study is to compare 30-day survival outcomes between the icECMO and dcECMO approaches in RPCS patients. Secondary endpoints include the evaluation of adverse events and the identification of predictors that influence 30-day mortality. Results The study included 60 patients, 25 received icECMO and 35 treated with dcECMO due to RPCS. The icECMO group demonstrated significantly better 30-day survival rates (icECMO; 10 [40%] vs. dcECMO; 5 [14.3%], log-rank test; p=0.042). Despite comparable ECMO flow rate and ECMO RPM (rotations per minute) in the first day between the study groups ([icECMO; 4.5 l/min vs. dcECMO; 4.6 l/min, p=0.124], [icECMO; 3510 rpm vs. dcECMO; 3800 rpm, p=0.115], respectively), lactate levels were significantly higher in the dcECMO group on the 1st and 3rd post-extracorporeal life support (ECLS) days (p=0.006 and p=0.008, respectively). Gastrointestinal ischemia was more common in the dcECMO group (p=0.036). Successful ECMO weaning was more frequent in the icECMO group (56% vs. 22.9%, p=0.014). Multivariable logistic regression identified arterial lactate on the first day with a cutoff 4 mmol/l as an independent risk factor for 30-day mortality with Exp(B) of 8.9 (p=0.007). Conclusions Our findings suggest a potential survival advantage with the icECMO technique in patients undergoing central ECMO cannulation after RPCS. However, larger prospective studies are essential to confirm this observation.
背景 中心静脉 - 动脉体外膜肺氧合（VA - ECMO）是用于支持心脏术后难治性心源性休克（RPCS）患者的常用策略。这种支持可通过封闭胸腔的间接中心ECMO（icECMO）或开放胸腔的直接中心ECMO（dcECMO）来提供。方法 这项单中心回顾性分析纳入了2019年1月至2020年12月期间60例因RPCS接受中心VA - ECMO治疗的患者。本研究的主要终点是比较RPCS患者中icECMO和dcECMO两种方法的30天生存结局。次要终点包括不良事件评估以及确定影响30天死亡率的预测因素。结果 该研究纳入60例患者，其中25例因RPCS接受icECMO治疗，35例接受dcECMO治疗。icECMO组的30天生存率显著更高（icECMO组；10例[40%] vs. dcECMO组；5例[14.3%]，对数秩检验；p = 0.042）。尽管研究组之间第一天的ECMO流速和ECMO每分钟转速（RPM）相当（[icECMO组；4.5升/分钟 vs. dcECMO组；4.6升/分钟，p = 0.124]，[icECMO组；3510转/分钟 vs. dcECMO组；3800转/分钟，p = 0.115]），但在体外生命支持（ECLS）后第1天和第3天，dcECMO组的乳酸水平显著更高（分别为p = 0.006和p = 0.008）。dcECMO组胃肠道缺血更常见（p = 0.036）。icECMO组成功撤机的频率更高（56% vs. 22.9%，p = 0.014）。多变量逻辑回归确定第一天动脉血乳酸水平≥4 mmol/l为30天死亡率的独立危险因素，Exp(B)为8.9（p = 0.007）。结论 我们的研究结果表明，对于RPCS后接受中心ECMO插管的患者，icECMO技术可能具有生存优势。然而，需要更大规模的前瞻性研究来证实这一观察结果。
