Wulfran Bougouin1, Nadia Aissaoui2, Alain Combes3, Nicolas Deye4, Lionel Lamhaut5, Daniel Jost6, Carole Maupain7, Frankie Beganton8, Adrien Bouglé9, Nicole Karam1, Florence Dumas10, Eloi Marijon1, Xavier Jouven1, Alain Cariou11. 1. Cardiology Department, Pompidou Hospital, APHP, Paris, France; Paris-Cardiovascular-Research-Center, INSERM U970, Paris, France; Université Paris-Descartes-Sorbonne-Paris-Cité, Paris, France; Paris Sudden-Death-Expertise-Center, Paris, France. 2. Université Paris-Descartes-Sorbonne-Paris-Cité, Paris, France; Medical ICU, Pompidou Hospital, APHP, Paris, France. 3. Medical-Surgical Intensive Care Unit, iCAN, Institute of Cardiometabolism and Nutrition, Pitié-Salpétrière Hospital, APHP, Paris, France. 4. Medical ICU, Lariboisière Hospital, AP-HP, Paris, France; INSERM U942, Paris, France. 5. Paris-Cardiovascular-Research-Center, INSERM U970, Paris, France; Université Paris-Descartes-Sorbonne-Paris-Cité, Paris, France; Paris Sudden-Death-Expertise-Center, Paris, France; ICU and SAMU 75, Necker Enfants-Malades Hospital, Paris, France. 6. Paris Sudden-Death-Expertise-Center, Paris, France; Paris Fire Brigade Emergency Dept., Paris, France. 7. Cardiology Department, Pitié-Salpétrière Hospital, APHP, Paris, France. 8. Paris-Cardiovascular-Research-Center, INSERM U970, Paris, France; Université Paris-Descartes-Sorbonne-Paris-Cité, Paris, France; Paris Sudden-Death-Expertise-Center, Paris, France. 9. Human Histopathology and Animal Models Unit, Infection and Epidemiology Department, Institut Pasteur, Paris, France; Anesthesiology and Intensive Care, Institut de Cardiologie, Pitié-Salpétrière Hospital, Paris, France. 10. Paris-Cardiovascular-Research-Center, INSERM U970, Paris, France; Université Paris-Descartes-Sorbonne-Paris-Cité, Paris, France; Paris Sudden-Death-Expertise-Center, Paris, France; Emergency Department, Cochin-Hotel-Dieu Hospital, APHP, Paris, France. 11. Paris-Cardiovascular-Research-Center, INSERM U970, Paris, France; Université Paris-Descartes-Sorbonne-Paris-Cité, Paris, France; Paris Sudden-Death-Expertise-Center, Paris, France; Medical ICU, Cochin Hospital, AP-HP, Paris, France. Electronic address: alain.cariou@cch.aphp.fr.
Abstract
PURPOSE: Cardiogenic shock due to post-resuscitation myocardial dysfunction is a major cause of mortality among patients hospitalized after cardiac arrest (CA). Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) has been proposed in the most severe cases but the level of evidence is very low. We assessed characteristics, outcome and prognostic factors of patients treated with VA-ECMO for post-CA shock. METHODS: Using a large regional registry, we focused on all CA admitted in ICU. Among those who developed a post-CA shock, prognostic was compared according to VA-ECMO use, using logistic regression and propensity score. Specific prognostic factors were identified among VA-ECMO patients. RESULTS: Among 2988 patients admitted after CA, 1489 developed a post-CA shock, and were included. They were mostly male (68%), with mean age 63 years (SD=15). Fiflty-two patients (3.5%) were treated with VA-ECMO, mostly patients with ischemic cause of CA (67%). Among patients with post-CA shock, 312 (21%) were discharged alive (25% in VA-ECMO group, 21% in control group, P=0.45). After adjustment for pre-hospital and in-hospital factors, survival did not differ among patients treated with VA-ECMO (OR for survival=0.9, 95%CI 0.4-2.3, P=0.84). After propensity-score matching, results were consistent. Among patients treated with VA-ECMO, initial arterial pH (OR=1.7 per 0.1 increase, 95%CI 1.0-2.8, P=0.04) and implantation of VA-ECMO over 24h after ROSC (OR=20.0, 95%CI 1.4-277.3, P=0.03) were associated with survival. CONCLUSIONS: Post-CA shock is frequent and is associated with a high mortality rate. When used in selected patients, we observed that VA-ECMO could be an appropriate treatment.
PURPOSE:Cardiogenic shock due to post-resuscitation myocardial dysfunction is a major cause of mortality among patients hospitalized after cardiac arrest (CA). Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) has been proposed in the most severe cases but the level of evidence is very low. We assessed characteristics, outcome and prognostic factors of patients treated with VA-ECMO for post-CA shock. METHODS: Using a large regional registry, we focused on all CA admitted in ICU. Among those who developed a post-CA shock, prognostic was compared according to VA-ECMO use, using logistic regression and propensity score. Specific prognostic factors were identified among VA-ECMO patients. RESULTS: Among 2988 patients admitted after CA, 1489 developed a post-CA shock, and were included. They were mostly male (68%), with mean age 63 years (SD=15). Fiflty-two patients (3.5%) were treated with VA-ECMO, mostly patients with ischemic cause of CA (67%). Among patients with post-CA shock, 312 (21%) were discharged alive (25% in VA-ECMO group, 21% in control group, P=0.45). After adjustment for pre-hospital and in-hospital factors, survival did not differ among patients treated with VA-ECMO (OR for survival=0.9, 95%CI 0.4-2.3, P=0.84). After propensity-score matching, results were consistent. Among patients treated with VA-ECMO, initial arterial pH (OR=1.7 per 0.1 increase, 95%CI 1.0-2.8, P=0.04) and implantation of VA-ECMO over 24h after ROSC (OR=20.0, 95%CI 1.4-277.3, P=0.03) were associated with survival. CONCLUSIONS: Post-CA shock is frequent and is associated with a high mortality rate. When used in selected patients, we observed that VA-ECMO could be an appropriate treatment.
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