Giuseppe Maria Raffa1, Mariusz Kowalewski2, Daniel Brodie3, Mark Ogino4, Glenn Whitman5, Paolo Meani6, Michele Pilato7, Antonio Arcadipane8, Thijs Delnoij6, Eshan Natour9, Sandro Gelsomino9, Jos Maessen9, Roberto Lorusso9. 1. Department of Cardiothoracic Surgery, Heart and Vascular Center, Maastricht University Medical Centre, Maastricht, The Netherlands; Department for the Treatment and Study of Cardiothoracic Diseases and Cardiothoracic Transplantation, IRCCS-ISMETT (Istituto Mediterraneo per i Trapianti e Terapie ad alta specializzazione), Palermo, Italy. Electronic address: giuseppe.raffa78@gmail.com. 2. Clinical Department of Cardiac Surgery, Central Clinical Hospital of the Ministry of Interior in Warsaw, Warsaw, Poland; Cardiothoracic Research Center, Collegium Medicum, Nicolaus Copernicus University, Bydgoszcz, Poland. 3. Division of Pulmonary and Critical Care Medicine, Columbia University College of Physicians and Surgeons/New York-Presbyterian Hospital, New York, New York. 4. Division of Neonatology, Alfred I. DuPont Hospital for Children, Wilmington, Delaware. 5. Cardiovascular Surgery Intensive Care Unit, Johns Hopkins Hospital, Baltimore, Maryland; Heart Transplant, Johns Hopkins Hospital, Baltimore, Maryland. 6. Intensive Care Unit, Heart and Vascular Center, Maastricht University Medical Center, Maastricht, The Netherlands; Department of Cardiology, Heart and Vascular Center, Maastricht University Medical Center, Maastricht, The Netherlands. 7. Department for the Treatment and Study of Cardiothoracic Diseases and Cardiothoracic Transplantation, IRCCS-ISMETT (Istituto Mediterraneo per i Trapianti e Terapie ad alta specializzazione), Palermo, Italy. 8. Department of Anesthesia and Intensive Care, IRCCS-ISMETT (Istituto Mediterraneo per i Trapianti e Terapie ad alta specializzazione), Palermo, Italy. 9. Department of Cardiothoracic Surgery, Heart and Vascular Center, Maastricht University Medical Centre, Maastricht, The Netherlands.
Abstract
BACKGROUND: Venoarterial (VA) extracorporeal membrane oxygenation (ECMO) application in postcardiotomy shock (PCS) and non-PCS is increasing. VA-ECMO plays a critical role in the management of these patients, yet may be associated with serious complications. METHODS: A systematic review of all available reports in the literature of patients receiving VA-ECMO, either directly or indirectly, comparing central cannulation (right atrial to ascending aorta) versus peripheral cannulation (femoral vein to femoral artery or axillary artery) were analyzed. The primary endpoint was survival. Cerebrovascular events, limb complications, bleeding requiring reoperation, sepsis, continuous venovenous hemofiltration, and transfusions were also assessed in both groups. RESULTS: Seventeen retrospective case series clearly describing the VA-ECMO access and including 1,691 patients with PCS and non-PCS were found. The peripheral approach was more commonly used (980 patients, 57.9%) than the central one. There was no difference in the analysis between the two techniques regarding all-cause mortality risk ratio (1.00, 95% confidence interval: 0.94 to 1.08, I2 = 0%, p = 0.92). No statistical differences were found between peripheral and central VA-ECMO with regard to cerebrovascular events, limb complications, or sepsis rates. Peripheral cannulation was associated with a significant reduction in the risk of bleeding (p = 0.02), continuous venovenous hemofiltration (p = 0.03), transfusion of red blood cells units (p < 0.00001), fresh frozen plasma units (p = 0.0002), and platelets units (p < 0.00001). CONCLUSIONS: Peripheral and central VA-ECMO configurations showed comparable inhospital survival for PCS and non-PCS. The risk of bleeding, continuous venovenous hemofiltration, and blood product transfusion was significantly lower with the peripheral cannulation strategy.
BACKGROUND: Venoarterial (VA) extracorporeal membrane oxygenation (ECMO) application in postcardiotomy shock (PCS) and non-PCS is increasing. VA-ECMO plays a critical role in the management of these patients, yet may be associated with serious complications. METHODS: A systematic review of all available reports in the literature of patients receiving VA-ECMO, either directly or indirectly, comparing central cannulation (right atrial to ascending aorta) versus peripheral cannulation (femoral vein to femoral artery or axillary artery) were analyzed. The primary endpoint was survival. Cerebrovascular events, limb complications, bleeding requiring reoperation, sepsis, continuous venovenous hemofiltration, and transfusions were also assessed in both groups. RESULTS: Seventeen retrospective case series clearly describing the VA-ECMO access and including 1,691 patients with PCS and non-PCS were found. The peripheral approach was more commonly used (980 patients, 57.9%) than the central one. There was no difference in the analysis between the two techniques regarding all-cause mortality risk ratio (1.00, 95% confidence interval: 0.94 to 1.08, I2 = 0%, p = 0.92). No statistical differences were found between peripheral and central VA-ECMO with regard to cerebrovascular events, limb complications, or sepsis rates. Peripheral cannulation was associated with a significant reduction in the risk of bleeding (p = 0.02), continuous venovenous hemofiltration (p = 0.03), transfusion of red blood cells units (p < 0.00001), fresh frozen plasma units (p = 0.0002), and platelets units (p < 0.00001). CONCLUSIONS: Peripheral and central VA-ECMO configurations showed comparable inhospital survival for PCS and non-PCS. The risk of bleeding, continuous venovenous hemofiltration, and blood product transfusion was significantly lower with the peripheral cannulation strategy.
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