Venous-Arterial to Venous Venous Extra-Corporeal Membrane Oxygenation Conversion Methodology for Improving Cardiogenic Shock Outcomes: A Paradigm Shift

• Published in: The Journal of heart and lung transplantation Vol. 40; no. 4; p. S408
• Main Authors: Gidea, C.G., Toy, B., Reyentovich, A., Fargnoli, A., Piper, G., Lewis, T., Saraon, T., Rao, S., Goldberg, R., Kadosh, B., Kon, Z., Moazami, N., Smith, D.
• Format: Journal Article
• Language: English
• Published: Elsevier Inc 01-04-2021
• ISSN: 1053-2498; 1557-3117
• DOI: 10.1016/j.healun.2021.01.1147

Despite improvements in selection and management of patients on extra-corporeal membrane oxygenation (ECMO) the overall outcomes of patients in cardiogenic shock (CS) supported with veno-arterial (VA) ECMO can be improved. In particular, a significant percentage of patients who survive ECMO do not survive to hospital discharge. We reviewed our ECMO outcomes with a specific focus on reducing the inter-stage mortality for patients with cardiogenic shock supported with VA-ECMO.
We conducted a retrospective, single center study from 11/2016 to 10/2020, reviewing all adult VA-ECMO cases. Patients who were offered VA-ECMO support as part of a bridge to lung transplant or intra-operative support for lung transplant and eCPR (n=30) were excluded. Based on one specific inter-stage mortality we adjusted our strategy and divided our patients on ERA1 (11/2016-11/2018) and ERA2 (11/2018 -10/2020). This leaves ERA1 (n= 38) and ERA2 (n= 36) patients. Patient demographics, baseline characteristics and clinical outcomes were compared.
There was no difference in demographics between groups: median age or gender between the ERA 1 versus ERA 2 (p= 0.42 and p = 0.17, respectively). The groups were the same in terms of indication for ECMO (STEMI/ADHF/PCCS) and cannulation strategies were similar (peripheral and central). Although there was a trend toward lower inter-stage mortality (39% vs 21%, p = 0.07), this did not reach statistical significance. Survival to discharge was 60% and 79% (p=0.07) in ERA 1 and ERA 2, respectively. For the cohort of patients who were bridged with inter-stage VV-ECMO in ERA2, the survival to discharge rate was 7/9 (78%) The conversion strategy resulted in a longer ECMO period of 8±1 versus 5±1 days, (p< 0.01)..
Reducing inter-stage mortality for patients with cardiogenic shock supported by VA-ECMO remains an area for improvement. Selecting patients with evidence of recovery of ventricular function but need for a period of support for gas exchange (VV ECMO) may be helpful in reducing mortality in these patients.