Is Extracorporeal Membrane Oxygenation an Option in Patients with Refractory Postcardiotomy Cardiogenic Shock? Long-Term Follow-up Over 1,500 Consecutive Adult Patients

Introduction: The aim of the study was to evaluate the perioperative and long-term outcomes of patients undergoing extracorporeal membrane oxygenation (ECMO) for refractory postcardiotomy cardiogenic shock at our high-volume tertiary care center.

Methods: We analyzed all patients undergoing ECMO therapy (n = 1,501; age = 56.3 ± 20.6; 68.4% male) between November 1997 and August 2018 at our high-volume center. Follow-up range was from 0 to 19 years (mean 1.6 ± 3.3 years) and was complete in 100%.

Results: Patient mean body mass index was 26.9 ± 7.1 kg/m², and the following risk factors were present: diabetes (30.4% of patients), arterial hypertension (70%), pulmonary hypertension (25.1%), smoking (35.1%), chronic obstructive pulmonary disease (5.0%), peripheral arterial disease (23.8%), and preoperative dialysis (6.2%). Preoperative left ventricular ejection fraction was 43.1 ± 18% and preoperative inotropic was required in 30.7% of patients. Isolated CABG was performed in 22.3% and isolated valve procedure in 11.3% of patients, with emergency surgery being performed in 46.2%. Major complications consisted of massive bleeding in 38.6% of patients with transfusion requirements of 25.5 ± 26 packed red blood cells and 22.1 ± 24 FFP; postoperative dialysis (59.2%); tracheotomy in 32.1%; and stroke in 12.4%. Survival was 44.6 ± 1.4% at 30 days, 26.1 ± 1.2% at 5 years, 23.4 ± 1.3% at 10 years, and 22.1 ± 1.6% at 15 years. Patients who were discharged from hospital had a 5-year survival rate of 68.2 ± 2.1% and 10-year survival rate of 61.2 ± 2.7%. Multivariate regression analysis revealed active smoking (p = 0.01; odds ratio [OR]: 2.4), chronic obstructive pulmonary disease (p = 0.04; OR: 2.0), peripheral arterial disease (p = 0.01; OR: 2.8), and atrial fibrillation (p = 0.01; OR: 2.8) as independent risk factors for mortality. Cox analysis revealed following predictors for long-term mortality: diabetes mellitus (p < 0.01; hazard ratio [HR]: 5.5), pulmonary hypertension (p = 0.02; HR: 3.3), perioperative myocardial infarct (p < 0.01; HR: 1.7), and postoperative dialysis (p < 0.01 HR: 1.8).

Conclusion: ECMO support is an acceptable option for patients with postcardiotomy cardiogenic shock and is justified by good long-term outcome of hospital survivors. Nonetheless, morbidity and mortality rates are substantial.