Mariusz Kowalewski1,2,3,4,5,6,7,8,9,10,11,12,13, Kamil Zieliński4, Giuseppe Maria Raffa5, Paolo Meani1,6,7, Valeria Lo Coco1,5, Federica Jiritano1,6,7, Dario Fina1,8, Matteo Matteucci1,9, Giovanni Chiarini1,10,11, Anne Willers1, Jorik Simons1, Piotr Suwalski2, Mario Gaudino12, Michele Di Mauro13, Jos Maessen1,13, Roberto Lorusso1,13. 1. Department of Cardio-Thoracic Surgery, Heart and Vascular Centre, Maastricht University Medical Centre (MUMC), Maastricht, The Netherlands. 2. Clinical Department of Cardiac Surgery, Central Clinical Hospital of the Ministry of Interior and Administration, Centre of Postgraduate Medical Education, Warsaw, Poland. 3. Thoracic Research Centre, Collegium Medicum Nicolaus Copernicus University, Innovative Medical Forum, Bydgoszcz, Poland. 4. Warsaw Medical University, Warsaw, Poland. 5. Cardiac Surgery Unit, ISMETT, Palermo, Italy. 6. Cardiology Unit, Niguarda Hospital, Milan, Italy. 7. Cardiac Surgery Unit, University of Catanzaro, Catanzaro, Italy. 8. Cardiology Unit, San Donato Hospital, Milan, Italy. 9. Cardiac Surgery Unit, Ospedale di Circolo, University of Varese, Varese, Italy. 10. 2nd Intensive Care Unit, Ospedale Civile, University of Brescia, Brescia, Italy. 11. Department of Cardio-Thoracic Surgery, Well Cornell Medicine, New York, NY. 12. Cardiac Surgery Unit, University Hospital, University of Chieti, Chieti, Italy. 13. Cardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherlands.
Abstract
OBJECTIVES: Because significantly higher mortality is observed in elderly patients undergoing venoarterial extracorporeal membrane oxygenation for refractory cardiogenic shock, decision-making in this setting is challenging. We aimed to elucidate predictors of unfavorable outcomes in these elderly (≥ 70 yr) patients. DESIGN: Analysis of international worldwide extracorporeal life support organization registry. SETTING: Refractory cardiogenic shock due to various etiologies (cardiac arrest excluded). PATIENTS: Elderly patients (≥ 70 yr). INTERVENTIONS: Venoarterial extracorporeal membrane oxygenation. MEASUREMENTS AND MAIN RESULTS: Three age groups (70-74, 75-79, ≥80 yr) were in-depth analyzed. Uni- and multivariable analysis were performed. From January 1997 to December 2018, 2,644 patients greater than or equal to 70 years (1,395 [52.8%] 70-74 yr old, 858 [32.5%] 75-79 yr, and 391 [14.8%] ≥ 80 yr old) were submitted to venoarterial extracorporeal membrane oxygenation for refractory cardiogenic shock with marked increase in the most recent years. Peripheral access was applied in majority of patients. Median extracorporeal membrane oxygenation support duration was 3.5 days (interquartile range: 1.6-6.1 d), (3.9 d [3.7-4.6 d] in patients ≥ 80 yr) (p < 0.001). Weaning from extracorporeal membrane oxygenation was possible in 1,236 patients (46.7%). Overall in-hospital mortality was estimated at 68.3% with highest crude mortality rates observed in 75-79 years old subgroup (70.1%). Complications were mostly cardiovascular and bleeding, without apparent differences between subgroups. Airway pressures, 24-hour pH after extracorporeal membrane oxygenation start, extracorporeal membrane oxygenation duration, and renal replacement therapy were predictive of higher mortality. In-hospital mortality was lower in heart transplantation recipients, posttranscatheter aortic valve replacement, and pulmonary embolism; conversely, higher mortality followed extracorporeal membrane oxygenation institution after coronary artery bypass + valve and in decompensated chronic heart failure, and nearly 100% mortality followed in extracorporeal membrane oxygenation for sepsis. CONCLUSIONS: This study confirmed the remarkable increase of venoarterial extracorporeal membrane oxygenation use in elderly affected by refractory cardiogenic shock. Despite in-hospital mortality remains high, venoarterial extracorporeal membrane oxygenation should still be considered in such setting even in elderly patients, since increasing age itself was not linked to increased mortality, whereas several predictors may guide indication and management.
OBJECTIVES: Because significantly higher mortality is observed in elderly patients undergoing venoarterial extracorporeal membrane oxygenation for refractory cardiogenic shock, decision-making in this setting is challenging. We aimed to elucidate predictors of unfavorable outcomes in these elderly (≥ 70 yr) patients. DESIGN: Analysis of international worldwide extracorporeal life support organization registry. SETTING:Refractory cardiogenic shock due to various etiologies (cardiac arrest excluded). PATIENTS: Elderly patients (≥ 70 yr). INTERVENTIONS: Venoarterial extracorporeal membrane oxygenation. MEASUREMENTS AND MAIN RESULTS: Three age groups (70-74, 75-79, ≥80 yr) were in-depth analyzed. Uni- and multivariable analysis were performed. From January 1997 to December 2018, 2,644 patients greater than or equal to 70 years (1,395 [52.8%] 70-74 yr old, 858 [32.5%] 75-79 yr, and 391 [14.8%] ≥ 80 yr old) were submitted to venoarterial extracorporeal membrane oxygenation for refractory cardiogenic shock with marked increase in the most recent years. Peripheral access was applied in majority of patients. Median extracorporeal membrane oxygenation support duration was 3.5 days (interquartile range: 1.6-6.1 d), (3.9 d [3.7-4.6 d] in patients ≥ 80 yr) (p < 0.001). Weaning from extracorporeal membrane oxygenation was possible in 1,236 patients (46.7%). Overall in-hospital mortality was estimated at 68.3% with highest crude mortality rates observed in 75-79 years old subgroup (70.1%). Complications were mostly cardiovascular and bleeding, without apparent differences between subgroups. Airway pressures, 24-hour pH after extracorporeal membrane oxygenation start, extracorporeal membrane oxygenation duration, and renal replacement therapy were predictive of higher mortality. In-hospital mortality was lower in heart transplantation recipients, posttranscatheter aortic valve replacement, and pulmonary embolism; conversely, higher mortality followed extracorporeal membrane oxygenation institution after coronary artery bypass + valve and in decompensated chronic heart failure, and nearly 100% mortality followed in extracorporeal membrane oxygenation for sepsis. CONCLUSIONS: This study confirmed the remarkable increase of venoarterial extracorporeal membrane oxygenation use in elderly affected by refractory cardiogenic shock. Despite in-hospital mortality remains high, venoarterial extracorporeal membrane oxygenation should still be considered in such setting even in elderly patients, since increasing age itself was not linked to increased mortality, whereas several predictors may guide indication and management.
Authors: Mariusz Kowalewski; Kamil Zieliński; Daniel Brodie; Graeme MacLaren; Glenn Whitman; Giuseppe M Raffa; Udo Boeken; Kiran Shekar; Yih-Sharng Chen; Christian Bermudez; David D'Alessandro; Xiaotong Hou; Jonathan Haft; Jan Belohlavek; Inga Dziembowska; Piotr Suwalski; Peta Alexander; Ryan P Barbaro; Mario Gaudino; Michele Di Mauro; Jos Maessen; Roberto Lorusso Journal: Crit Care Med Date: 2021-07-01 Impact factor: 9.296
Authors: Dirk von Lewinski; Lukas Herold; Christian Stoffel; Sascha Pätzold; Friedrich Fruhwald; Siegfried Altmanninger-Sock; Ewald Kolesnik; Markus Wallner; Peter Rainer; Heiko Bugger; Nicolas Verheyen; Ursula Rohrer; Martin Manninger-Wünscher; Daniel Scherr; Dietmar Renz; Ameli Yates; Andreas Zirlik; Gabor G Toth Journal: Catheter Cardiovasc Interv Date: 2022-07-13 Impact factor: 2.585