Time course, factors related to, and prognostic impact of venoarterial extracorporeal membrane flow in cardiogenic shock
Por:
Montero S., Rivas-Lasarte M., Huang F., Chommeloux J., Demondion P., Bréchot N., Hékimian G., Franchineau G., Persichini R., Luyt C.-É., Garcia-Garcia C., Bayes-Genis A., Lebreton G., Cinca J., Leprince P., Combes A., Alvarez-Garcia J., Schmidt M.
Publicada:
1 ene 2023
Ahead of Print:
11 nov 2022
Resumen:
Aims: Venoarterial extracorporeal membrane oxygenation (VA-ECMO) is currently one of the most used devices in refractory cardiogenic shock. However, there is a lack of evidence on how to set the ‘optimal’ flow. We aimed to describe the evolution of VA-ECMO flows in a cardiogenic shock population and determine the risk factors of ‘high-ECMO flow’. Methods and results: A 7 year database of patients supported with VA-ECMO was used. Based on the median flow during the first 48 h of the VA-ECMO run, patients were classified as ‘high-flow’ or ‘low-flow’, respectively, when median ECMO flow was =3.6 or <3.6 L/min. Outcomes included rates of ventilator-associated pneumonia, ECMO-related complications, days on ECMO, days on mechanical ventilation, intensive care unit and hospitalization lengths of stay, and in-hospital and 60 day mortality. Risk factors of high-ECMO flow were assessed using univariate and multivariate cox regression. The study population included 209 patients on VA-ECMO, median age was 51 (40–59) years, and 78% were males. The most frequent aetiology leading to cardiogenic shock was end-stage dilated cardiomyopathy (57%), followed by acute myocardial infarction (23%) and fulminant myocarditis (17%). Among the 209 patients, 105 (50%) were classified as ‘high-flow’. This group had a higher rate of ischaemic aetiology (16% vs. 30%, P = 0.023) and was sicker at admission, in terms of worse Simplified Acute Physiology Score II score [40 (26–58) vs. 56 (42–74), P < 0.001], higher lactate [3.6 (2.2–5.8) mmol/L vs. 5.2 (3–9.7) mmol/L, P < 0.001], and higher aspartate aminotransferase [97 (41–375) U/L vs. 309 (85–939) U/L, P < 0.001], among others. The ‘low-flow’ group had less ventilator-associated pneumonia (40% vs. 59%, P = 0.007) and less days on mechanical ventilation [4 (1.5–7.5) vs. 6 (3–12) days, P = 0.009]. No differences were found in lengths of stay or survival according to the ECMO flow. The multivariate analysis showed that risk factors independently associated with ‘high-flow’ were mechanical ventilation at cannulation [odds ratio (OR) 3.9, 95% confidence interval (CI) 2.1–7.1] and pre-ECMO lactate (OR 1.1, 95% CI 1.0–1.2). Conclusions: In patients with refractory cardiogenic shock supported with VA-ECMO, sicker patients had higher support since early phases, presenting thereafter higher rates of ventilator-associated pneumonia but similar survival compared with patients with lower flows. © 2022 The Authors. ESC Heart Failure published by John Wiley & Sons Ltd on behalf of European Society of Cardiology.
Filiaciones:
Montero S.:
Acute Cardiovascular Care Unit, Cardiology, Hospital Germans Trias i Pujol, Departament de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain
Medical Intensive Care Unit, Assistance Publique–Hôpitaux de Paris, Pitié–Salpêtrière Hospital, Paris Cedex 13, France
Rivas-Lasarte M.:
Advanced Heart Failure and Heart Transplant Unit, Cardiology Department, Hospital Universitario Puerta de Hierro Majadahonda, CIBERCV, Madrid, Spain
Huang F.:
Medical Intensive Care Unit, Assistance Publique–Hôpitaux de Paris, Pitié–Salpêtrière Hospital, Paris Cedex 13, France
Chommeloux J.:
Medical Intensive Care Unit, Assistance Publique–Hôpitaux de Paris, Pitié–Salpêtrière Hospital, Paris Cedex 13, France
Demondion P.:
Thoracic and Cardiovascular Department, Assistance Publique–Hôpitaux de Paris, Pitié–Salpêtrière Hospital, Paris Cedex 13, France
Institute of Cardiometabolism and Nutrition, Sorbonne Université, INSERM UMRS_1166-iCAN, Paris Cedex 13, 75651, France
Bréchot N.:
Medical Intensive Care Unit, Assistance Publique–Hôpitaux de Paris, Pitié–Salpêtrière Hospital, Paris Cedex 13, France
Institute of Cardiometabolism and Nutrition, Sorbonne Université, INSERM UMRS_1166-iCAN, Paris Cedex 13, 75651, France
Hékimian G.:
Medical Intensive Care Unit, Assistance Publique–Hôpitaux de Paris, Pitié–Salpêtrière Hospital, Paris Cedex 13, France
Institute of Cardiometabolism and Nutrition, Sorbonne Université, INSERM UMRS_1166-iCAN, Paris Cedex 13, 75651, France
Franchineau G.:
Medical Intensive Care Unit, Assistance Publique–Hôpitaux de Paris, Pitié–Salpêtrière Hospital, Paris Cedex 13, France
Institute of Cardiometabolism and Nutrition, Sorbonne Université, INSERM UMRS_1166-iCAN, Paris Cedex 13, 75651, France
Persichini R.:
Medical–Surgical Intensive Care Unit, CHU de La Réunion, Felix-Guyon Hospital, La Réunion, Saint Denis, France
Luyt C.-É.:
Medical Intensive Care Unit, Assistance Publique–Hôpitaux de Paris, Pitié–Salpêtrière Hospital, Paris Cedex 13, France
Institute of Cardiometabolism and Nutrition, Sorbonne Université, INSERM UMRS_1166-iCAN, Paris Cedex 13, 75651, France
Garcia-Garcia C.:
Acute Cardiovascular Care Unit, Cardiology, Hospital Germans Trias i Pujol, Departament de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain
Bayes-Genis A.:
Acute Cardiovascular Care Unit, Cardiology, Hospital Germans Trias i Pujol, Departament de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain
Lebreton G.:
Thoracic and Cardiovascular Department, Assistance Publique–Hôpitaux de Paris, Pitié–Salpêtrière Hospital, Paris Cedex 13, France
Institute of Cardiometabolism and Nutrition, Sorbonne Université, INSERM UMRS_1166-iCAN, Paris Cedex 13, 75651, France
Cinca J.:
Cardiology Department, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain
Leprince P.:
Thoracic and Cardiovascular Department, Assistance Publique–Hôpitaux de Paris, Pitié–Salpêtrière Hospital, Paris Cedex 13, France
Institute of Cardiometabolism and Nutrition, Sorbonne Université, INSERM UMRS_1166-iCAN, Paris Cedex 13, 75651, France
Combes A.:
Medical Intensive Care Unit, Assistance Publique–Hôpitaux de Paris, Pitié–Salpêtrière Hospital, Paris Cedex 13, France
Institute of Cardiometabolism and Nutrition, Sorbonne Université, INSERM UMRS_1166-iCAN, Paris Cedex 13, 75651, France
Alvarez-Garcia J.:
Cardiology Department, Hospital Ramón y Cajal, Centro de Investigación en Red en Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
Schmidt M.:
Medical Intensive Care Unit, Assistance Publique–Hôpitaux de Paris, Pitié–Salpêtrière Hospital, Paris Cedex 13, France
Institute of Cardiometabolism and Nutrition, Sorbonne Université, INSERM UMRS_1166-iCAN, Paris Cedex 13, 75651, France
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