Venoarterial Extracorporeal Membrane Oxygenation for Cardiogenic Shock and Cardiac Arrest: A Meta-Analysis

doi:10.1053/j.jvca.2014.09.005

Journal of Cardiothoracic and Vascular Anesthesia

Volume 29, Issue 3, June 2015, Pages 637-645

https://doi.org/10.1053/j.jvca.2014.09.005 Get rights and content

Objective

To evaluate the effect of extracorporeal membrane oxygenation (ECMO) on survival and complication rates in adults with refractory cardiogenic shock or cardiac arrest.

Design

Meta-analysis.

Setting

University hospitals.

Participants

One thousand one hundred ninety-nine patients from 22 observational studies.

Interventions

None.

Measurements and Main Results

Observational studies published from the year 2000 onwards, examining at least 10 adult patients who received ECMO for refractory cardiogenic shock or cardiac arrest were included. Pooled estimates with 95% confidence intervals were calculated based on the Freeman-Tukey double-arcsine transformation and DerSimonian-Laird random-effect model. Survival to discharge was 40.2% (95% confidence intervals [CI], 33.9-46.7), while survival at 3, 6, and 12 months was 55.9% (95% CI, 41.5-69.8), 47.6% (95% CI, 25.4-70.2), and 54.4% (95% CI, 36.6-71.7), respectively. Survival up to 30 days was higher in cardiogenic shock patients (52.5%, 95% CI, 43.7%-61.2%) compared to cardiac arrest (36.2%, 95% CI, 23.1%-50.4%). Concurrently, complication rates were particularly substantial for neurologic deficits (13.3%, 95% CI, 8.3-19.3), infection (25.1%, 95%CI, 15.9-35.5), and renal impairment (47.4%, 95% CI, 30.2-64.9). Significant heterogeneity was detected, although its levels were similar to previous meta-analyses that only examined short-term survival to discharge.

Conclusions

Venoarterial ECMO can improve short-term survival in adults with refractory cardiogenic shock or cardiac arrest. It also may provide favorable long-term survival at up to 3 years postdischarge. However, ECMO also is associated with significant complication rates, which must be incorporated into the risk-benefit analysis when considering treatment. These findings require confirmation by large, adequately controlled and standardized trials with long-term follow-up.

Section snippets

Literature Search Strategy

Seven electronic databases, including MEDLINE, EMBASE, PubMed, Cochrane Central Register of Controlled Trials (CENTRAL), Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effectiveness, and Web of Science were searched for original published studies from their dates of inception to January 2014. To maximize sensitivity of the search strategy and identify all studies, the authors combined the terms: “ECLS” or “extracorporeal life support” or “extracorporeal membrane

Quality of Studies

A total of 2,355 references were identified through seven electronic database searches (Fig 1). After duplicate and irrelevant references were excluded, 120 potentially relevant articles were retrieved. After detailed full-text evaluation, 22 studies were selected for analysis. The characteristics of these studies are summarized in Table 1. In these 22 studies, a total of 1,199 adult patients (aged 18 years and over) received VA-ECMO. There were 12 groups of patients with cardiogenic shock (n =

Discussion

This meta-analysis provides a current review of short- and long-term survival rates for refractory patients who have received VA-ECMO, as well as morbidity due to complications.

In this study, survival to discharge overall was 40.2% (95% CI, 33.9-46.7), and 30-day survival was 52.8% (95% CI, 43.9-61.6). This finding is consistent with previous meta-analyses, which demonstrated a cumulative survival to discharge rate of 47.4±4.1% and 20.8% to 65.4%, respectively.15, 18 However, these studies did

Conclusions

VA-ECMO provides acceptable short-term survival for adult patients with cardiogenic shock or cardiac arrest and stable long-term survival outcomes at up to 3 years. These benefits, however, must be considered alongside the significant associated risks in the decision to institute ECMO. Although these findings were limited by the heterogeneity of included studies, in the absence of large randomized trials, pooled analysis represents the best available method for evaluating ECMO. Large,

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Extra Corporeal Life Support (ECLS) is an evolving therapy in therapy-resistant cardiogenic shock (CS). Vascular cannulation in emergency situations can be accomplished through puncture of the femoral vessels by specialised teams. Since lower limb ischemia constitutes one of the major complications following cannulation, a distal perfusion cannula (DPC) has emerged as standard of care. We here aimed to analyse the impact of the DPC on limb perfusion and 6-month survival rate.
In a retrospective study from January 2012 to December 2018, 98 patients with cardiogenic shock and peripheral (v-a) ECLS implantation with documented limb perfusion status were identified and analysed. Demographic data, laboratory parameters, cause of CS, comorbidities, limb perfusion complications and complication management were analysed.
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Lower limb ischemia remains a serious complication after peripheral ECLS cannulation in CS, especially when a DPC is absent. Standardised DPC implementation may reduce the rate of severe limb complications in peripheral ECLS.
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Original ArticleVenoarterial Extracorporeal Membrane Oxygenation for Cardiogenic Shock and Cardiac Arrest: A Meta-Analysis

Objective

Design

Setting

Participants

Interventions

Measurements and Main Results

Conclusions

Section snippets

Literature Search Strategy

Quality of Studies

Discussion

Conclusions

Resuscitation

Ann Thorac Surg

J Am Coll Cardiol

J Surg Res

Resuscitation

Ann Emerg Med

Am J Emerg Med

Resuscitation

Resuscitation

Ann Thorac Surg

Ann Thorac Surg

Lancet

Ann Thorac Surg

Control Clinical Trials

J Thorac Cardiovasc Surg

Ann Thorac Surg

Resuscitation

J Thorac Cardiovasc Surg

Int J Cardiol

Resuscitation

Resuscitation

J Thorac Cardiovasc Surg

J Am Coll Cardiol

Crit Care Resusc

Ann Thorac Surg

Ann Thorac Surg

Ann Thorac Surg

Ann Thorac Surg

Outcomes and long-term quality-of-life of patients supported by extracorporeal membrane oxygenation for refractory cardiogenic shock

Crit Care Med

Salvage peripheral extracorporeal membrane oxygenation using Cobe Revolution(R) centrifugal pump as a bridge to decision for acute refractory cardiogenic shock

J Cardiac Surg

Trends in management and outcomes of patients with acute myocardial infarction complicated by cardiogenic shock

JAMA

Original Article
Venoarterial Extracorporeal Membrane Oxygenation for Cardiogenic Shock and Cardiac Arrest: A Meta-Analysis