Postcardiotomy Venoarterial Extracorporeal Membrane Oxygenation

Overview

Cardiac surgery can be not infrequently complicated by cardiac low-output syndrome due to critical preoperative conditions such as cardiogenic shock, poor left ventricular function and severe myocardial ischemia. Suboptimal myocardial protection, technical errors at graft anastomoses or of prosthesis implantation, and hibernating myocardium may further contribute to cardiac low-output syndrome occurring immediately or shortly after cardiac surgery. In this setting, veno-arterial extracorporeal oxygenation (VA-ECMO) is the only means to provide cardiopulmonary support to recovery or as bridge to transplantation. Data on the real benefit of VA-ECMO after cardiac surgery is limited and often derived from heterogeneous patient populations, which prevent conclusive results on the benefits of VA-ECMO in this setting. This issue will be investigated in the present retrospective European multicenter study. In this setting, veno-arterial extracorporeal oxygenation (VA-ECMO) is the only means to provide cardiopulmonary support to recovery or as bridge to transplantation. Data on the real benefit of VA-ECMO after cardiac surgery is limited and often derived from heterogeneous populations of patients who underwent different cardiac procedures. Patients with cardiac low-output after surgery for aortic dissection or valve surgery are expected to have different baseline characteristics (such as age and comorbidities) and underlying cardiac disease than patients undergoing isolated coronary surgery. Furthermore, available studies included patients operated two decades ago and this does not provide an exact measure of the benefits of this treatment strategy. The possible benefits of using VA-ECMO after adult cardiac surgery will be investigated in this retrospective European multicenter study.

Study Type

  • Study Type: Observational
  • Study Design
    • Time Perspective: Retrospective
  • Study Primary Completion Date: June 30, 2020

Detailed Description

Cardiac surgery can be not infrequently complicated by cardiac low-output syndrome due to critical preoperative conditions such as cardiogenic shock, poor left ventricular function and severe myocardial ischemia. Prolonged aortic cross-clamping, ischemia-reperfusion injury, suboptimal myocardial protection, technical errors at graft anastomoses or of prosthesis implantation, and hibernating myocardium may further contribute to cardiac low-output syndrome occurring immediately or shortly after cardiac surgery. In this setting, veno-arterial extracorporeal oxygenation (VA-ECMO) is the only means to provide cardiopulmonary support to recovery or as bridge to transplantation. Data on the real benefit of VA-ECMO after cardiac surgery is limited and often derived from heterogeneous and small size series of patients who underwent different cardiac surgery procedures. Patients with cardiac low-output after surgery for aortic dissection or valve surgery are expected to have different baseline characteristics (such as age and comorbidities) and underlying cardiac disease than patients undergoing isolated coronary surgery. Furthermore, available studies included patients operated two decades ago and, in view of the development of perfusion technology and perioperative care, this does not provide an exact measure of the current benefits of this treatment strategy. Importantly, the role of intra-aortic balloon pump, left ventricular venting, duration of VA-ECMO and hospital experience should be evaluated. The investigators sought to investigate these issues in a large multicenter study. Patients and methods Patients who were treated with VA-ECMO for cardiac low-output after adult cardiac surgery (other than heart transplantation and/or implantation of a left ventricular assist device) in 21 centers of cardiac surgery from January 2010 to December 2017. Eligibility criteria – Patients aged > 18 years; – Patients who required VA-ECMO after elective, urgent or emergency adult cardiac surgery such as coronary surgery, heart valve surgery and/or aortic root surgery because of postoperative low-cardiac output syndrome and/or acute respiratory failure. Exclusion criteria – Patients aged < 18 years; – Any VA-ECMO implanted before index surgical procedure; – Patients who underwent postoperatively veno-venous ECMO; – Patients who required VA-ECMO after heart transplantation; – Patients who required VA-ECMO after any left ventricular assist device. Definition criteria Definition criteria and units of measurements are reported beside each baseline, operative and postoperative variables in the electronic datasheet. Outcomes 1. Hospital death 2. Late death 3. Stroke 4. Tracheostomy 5. Gastrointestinal complications 6. Deep sternal wound infection 7. Vascular access site infection 8. Blood stream infection 9. Peripheral vascular injury 10. Major lower limb amputation 11. New onset dialysis 12. Peak postoperative serum creatinine level 13. Nadir postoperative pH during VA-ECMO 14. Peak postoperative arterial lactate level 15. Nadir postoperative hemoglobin level 16. Chest drainage output 24 h after surgery 17. Number of red blood cells units transfused intra- and postoperatively 18. Reoperation for intrathoracic bleeding 19. Reoperation for peripheral cannulation-related bleeding 20. Intensive care unit length of stay 21. Death on VA-ECMO Analysis of clinical results The aim of this registry is to perform a number of analysis evaluating: 1. Early and late survival of postcardiotomy VA-ECMO; 2. Predictors and causes of in-hospital death after successful weaning from postcardiotomy VA-ECMO; 3. Comparative analysis of peripheral versus central postcardiotomy VA-ECMO; 4. VA-ECMO plus intra-aortic baloon pump vs. isolated VA-ECMO; 5. Determinants of outcome after prolonged postcardiotomy VA-ECMO (>5 days). Publication of results The results of these studies will be submitted for publication to international, peer-reviewed journals in the fields of critical care, cardiology or cardiac surgery.

Interventions

  • Device: Venoarterial extracorporeal oxygenation
    • Veno-arterial extracorporeal oxygenation (VA-ECMO) is inserted in the acute setting in case of cardiac low output after adult cardiac surgery in order to provide cardiopulmonary support to recovery or as bridge to transplantation.

Clinical Trial Outcome Measures

Primary Measures

  • Hospital death
    • Time Frame: Up to 30 days after the index cardiac surgery
    • All-cause death

Secondary Measures

  • Late death
    • Time Frame: Up to 7-year follow-up after the index cardiac surgery
    • All-cause death
  • Stroke
    • Time Frame: Up to 30 days after the index cardiac surgery
    • Ischemic infarction or hemorrhagic injury of the brain
  • Tracheostomy
    • Time Frame: Up to 30 days after the index cardiac surgery
    • Respiratory failure requiring tracheostomy
  • Gastrointestinal complications
    • Time Frame: Up to 30 days after the index cardiac surgery
    • Gastrointestinal complications requiring surgical treatment
  • Deep sternal wound infection
    • Time Frame: Up to 30 days after the index cardiac surgery
    • Deep sternal wound infection or mediastinitis
  • Vascular access site infection
    • Time Frame: Up to 30 days after the index cardiac surgery
    • Infection secondary to any vascular access
  • Blood stream infection
    • Time Frame: Up to 30 days after the index cardiac surgery
    • Blood stream infection detected at blood cultures
  • Peripheral vascular injury
    • Time Frame: Up to 30 days after the index cardiac surgery
    • Any aortic and/or peripheral artery complications related to VA-ECMO
  • Major lower limb amputation
    • Time Frame: Up to 30 days after the index cardiac surgery
    • Major lower limb amputation
  • New onset dialysis
    • Time Frame: Up to 30 days after the index cardiac surgery
    • New onset dialysis
  • Peak postoperative serum creatinine level
    • Time Frame: Up to 30 days after the index cardiac surgery
    • Peak postoperative serum creatinine level
  • Nadir postoperative pH during VA-ECMO
    • Time Frame: Up to 30 days after the index cardiac surgery
    • Nadir postoperative pH during VA-ECMO
  • Peak postoperative arterial lactate level
    • Time Frame: Up to 30 days after the index cardiac surgery
    • Peak postoperative arterial lactate level
  • Nadir postoperative hemoglobin level
    • Time Frame: Up to 30 days after the index cardiac surgery
    • Nadir postoperative hemoglobin level
  • Chest drainage output 24 h after surgery
    • Time Frame: Up to 24 hours after the index cardiac surgery
    • Chest drainage output 24 h after surgery
  • Number of red blood cells units transfused intra- and postoperatively
    • Time Frame: Up to 30 days after the index cardiac surgery
    • Number of red blood cells units transfused intra- and postoperatively
  • Reoperation for intrathoracic bleeding
    • Time Frame: Up to 30 days after the index cardiac surgery
    • Reoperation for intrathoracic bleeding
  • Reoperation for peripheral cannulation-related bleeding
    • Time Frame: Up to 30 days after the index cardiac surgery
    • Reoperation for peripheral cannulation-related bleeding
  • Intensive care unit length of stay
    • Time Frame: Up to 30 days after the index cardiac surgery
    • Intensive care unit length of stay
  • Death on VA-ECMO
    • Time Frame: Up to 30 days after the index cardiac surgery
    • Death on VA-ECMO

Participating in This Clinical Trial

Inclusion Criteria

  • Patients who required VA-ECMO after elective, urgent or emergency adult cardiac surgery such as coronary surgery, heart valve surgery and/or aortic root surgery. Exclusion Criteria:

  • Any VA-ECMO implanted before index surgical procedure; – Patients who underwent postoperatively veno-venous ECMO; – Patients who required VA-ECMO after heart transplantation; – Patients who required VA-ECMO after any left ventricular assist device.

Gender Eligibility: All

Minimum Age: 18 Years

Maximum Age: N/A

Investigator Details

  • Lead Sponsor
    • Turku University Hospital
  • Collaborator
    • Karolinska Institutet
  • Provider of Information About this Clinical Study
    • Sponsor

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