Extracorporeal Membrane Oxygenator Bridge To Ventricular Assist Device Implantation for Patients in Profound Cardiogenic Shock Achieves Stabilization and Improved Results

Purpose: Extracorporeal membrane oxygenation (ECMO) is a common therapy for patients with severe respiratory failure or cardiogenic shock. Advances in technology and intensive care medicine led to a more liberal use for ECMO as rescue therapy. We observed a marked increase in ECMO implantations over the last 3 years. Thus, we sought to evaluate the outcome of our ECMO rescue program regarding indication, ECMO-related complications, and survival. Methods: Between 01/2011 and 07/2013 150 patients underwent ECMO therapy at the University Hospital Hamburg. Irreversible and disastrous morbidity and active bleeding were the only contraindications. A subgroup of 57 pts. received veno-venous (vv) ECMO, and 93 pts. received veno-arterial (va) ECMO. Patient demographics and ECMO-related complications assessed. Survival was defined as successful ECMO weaning and discharge from the ICU. Results: Mean pt. age was 52±15 years, with 34% pts. being female. Median hospitalization was 16 days, median ECMO run-time was 6 days. Predominant ECMO-related complications were bleeding (n= 57; 40%), lower leg ischemia (n= 16; 11%), and stroke (n= 7; 5%). Overall survival was 35% (n= 52). The occurrence of complications did not affect outcome. Subgroup analysis revealed 39% (n= 22) survival in vv vs. 32% (n= 32) in va pts. Indications for vv ECMO were ARDS (n= 51; 90%) and respiratory insufficiency (n= 6; 10%), while LCO (n= 79; 85%) was main indication for va ECMO. MI (n= 22), post-cardiotomy heart failure (HF) (n= 16), postintervention HF (n= 10), decompensated chronic HF (n= 8), sepsis (n= 8), and myocarditis (n= 6) were reasons for LCO. Va ECMO as a bridge to recovery in decompensated chronic HF was prognostically favorable (75% survival; p< 0.05), while infrequent causes for LCO (n= 9; intoxication, sarkoidosis, VAD-complications, TVP, pAH, mediastinal tumour, type A aortic dissections) showed high mortality (0% surv.; p< 0.05). The va group exhibited a higher incidence of stroke (n= 7 vs. n= 0; p< 0.05) and lower leg ischemia (n= 16 vs. n= 0; p= 0.001). Conclusion: Rescue ECMO therapy is feasible as ultima ratio for critically ill patients. Despite a substantial overall mortality, approx. one third of our patients survived and were successfully weaned. Notably, bridging to recovery in pts. with chronic heart failure showed excellent results. We believe this justifies our ECMO rescue strategy.