6-Year Single-Center Experience of Extracorporeal Life Support in Cardiogenic Shock: What Have We Learned, Where Are We Going?

Objectives: Extracorporeal Life Support (ECLS) is a well-established rescue treatment option for patients in refractory cardiogenic shock. Caseloads are constantly increasing worldwide and indications are expanding, now frequently including out-of-center implantations in remote hospitals, support of awake patients, and the concept of Extracorporeal Cardiopulmonary Resuscitation (ECPR). Here, we report on our single center 6-year experience.

Methods: The interdisciplinary ECLS-program of our university hospital was established in 2012. ECLS is implemented percutaneously via femoral access. Implantation is performed on-site and available 24/7. Since the launch of the program in February 2012 until January 2018, a total of 245 non-postcardiotomy patients underwent percutaneous femoral venoarterial ECLS implantation for refractory cardiogenic shock or ongoing CPR and were retrospectively analyzed with 30-day survival as the primary endpoint.

Results: 20% were female, mean age was 55 ± 14 years. Main etiologies were acute coronary syndromes (56%) and decompensated cardiomyopathies (18%). 73% had been resuscitated, 29% were ECPR cases. 27% underwent implantation in remote hospitals by our mobile team with subsequent air or ground transport to our center. 11% were awake at the time of ECLS implantation. Thirty-day survival was 47% (n = 116). Throughout the study period, we observed two peaks in mortality rates; one representing a learning phase and the other more liberal patient selection including rising ECPR numbers. Factors significantly associated with mortality were age, preimplantation pH as well as lactate levels, and implantation during ongoing CPR.

Conclusions: With gaining experience, we were able to discriminate factors that assist in triaging the patients. Age, past medical history, and CPR parameters in resuscitated patients are highly important but can be hard to obtain in the acute setting. Arterial pH, lactate and paO₂ levels are key factors rapidly measurable on-site providing essential information on the extent of cardiogenic shock, end-organ hypoperfusion and cellular hypoxia. We experienced learning curves demonstrating how far limits can(not) be pushed and by refining inclusion criteria as well as workflows we were able to achieve stable and substantial survival. Randomized trials are urgently needed to serve as an evidence-based background for international guidelines. Pre-hospital implantation as well as the definition of competence centers will have to be discussed.