Venoarterial Extracorporeal Membrane Oxygenation for Cardiopulmonary Support
2018; Lippincott Williams & Wilkins; Volume: 138; Issue: 20 Linguagem: Inglês
10.1161/circulationaha.118.036691
ISSN1524-4539
AutoresPeter Moritz Becher, Benedikt Schrage, Christoph Sinning, Bastian Schmack, Nina Fluschnik, Michael Schwarzl, Christoph Waldeyer, Diana Lindner, Moritz Seiffert, Franz–Josef Neumann, A. Bernhardt, Uwe Zeymer, Hölger Thiele, Hermann Reichenspurner, Stefan Blankenberg, Raphael Twerenbold, Dirk Westermann,
Tópico(s)Cardiac Arrest and Resuscitation
ResumoHomeCirculationVol. 138, No. 20Venoarterial Extracorporeal Membrane Oxygenation for Cardiopulmonary Support Free AccessLetterPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessLetterPDF/EPUBVenoarterial Extracorporeal Membrane Oxygenation for Cardiopulmonary SupportInsights From a German Registry Peter Moritz Becher, MD, Benedikt Schrage, MD, Christoph R. Sinning, MD, Bastian Schmack, MD, Nina Fluschnik, MD, Michael Schwarzl, MD, PhD, Christoph Waldeyer, MD, Diana Lindner, PhD, Moritz Seiffert, MD, Johannes T. Neumann, MD, Alexander M. Bernhardt, MD, Uwe Zeymer, MD, Holger Thiele, MD, Hermann Reichenspurner, MD, PhD, Stefan Blankenberg, MD, Raphael Twerenbold, MD and Dirk Westermann, MD Peter Moritz BecherPeter Moritz Becher Department of General and Interventional Cardiology, University Heart Center Hamburg, Germany (P.M.B., C.R.S., N.F., M.S., C.W., D.L., M.S., J.T.N., S.B., R.T., D.W.). , Benedikt SchrageBenedikt Schrage , Christoph R. SinningChristoph R. Sinning Department of General and Interventional Cardiology, University Heart Center Hamburg, Germany (P.M.B., C.R.S., N.F., M.S., C.W., D.L., M.S., J.T.N., S.B., R.T., D.W.). German Center for Cardiovascular Research, Partner Site Hamburg/Kiel/Lübeck (C.R.S., N.F., M.S., D.L., M.S., J.T.N., S.B., D.W.). , Bastian SchmackBastian Schmack Department of Cardiac Surgery, University Hospital Heidelberg, Germany (B.S.). , Nina FluschnikNina Fluschnik Department of General and Interventional Cardiology, University Heart Center Hamburg, Germany (P.M.B., C.R.S., N.F., M.S., C.W., D.L., M.S., J.T.N., S.B., R.T., D.W.). German Center for Cardiovascular Research, Partner Site Hamburg/Kiel/Lübeck (C.R.S., N.F., M.S., D.L., M.S., J.T.N., S.B., D.W.). , Michael SchwarzlMichael Schwarzl Department of General and Interventional Cardiology, University Heart Center Hamburg, Germany (P.M.B., C.R.S., N.F., M.S., C.W., D.L., M.S., J.T.N., S.B., R.T., D.W.). German Center for Cardiovascular Research, Partner Site Hamburg/Kiel/Lübeck (C.R.S., N.F., M.S., D.L., M.S., J.T.N., S.B., D.W.). , Christoph WaldeyerChristoph Waldeyer Department of General and Interventional Cardiology, University Heart Center Hamburg, Germany (P.M.B., C.R.S., N.F., M.S., C.W., D.L., M.S., J.T.N., S.B., R.T., D.W.). , Diana LindnerDiana Lindner Department of General and Interventional Cardiology, University Heart Center Hamburg, Germany (P.M.B., C.R.S., N.F., M.S., C.W., D.L., M.S., J.T.N., S.B., R.T., D.W.). German Center for Cardiovascular Research, Partner Site Hamburg/Kiel/Lübeck (C.R.S., N.F., M.S., D.L., M.S., J.T.N., S.B., D.W.). , Moritz SeiffertMoritz Seiffert Department of General and Interventional Cardiology, University Heart Center Hamburg, Germany (P.M.B., C.R.S., N.F., M.S., C.W., D.L., M.S., J.T.N., S.B., R.T., D.W.). German Center for Cardiovascular Research, Partner Site Hamburg/Kiel/Lübeck (C.R.S., N.F., M.S., D.L., M.S., J.T.N., S.B., D.W.). , Johannes T. NeumannJohannes T. Neumann Department of General and Interventional Cardiology, University Heart Center Hamburg, Germany (P.M.B., C.R.S., N.F., M.S., C.W., D.L., M.S., J.T.N., S.B., R.T., D.W.). German Center for Cardiovascular Research, Partner Site Hamburg/Kiel/Lübeck (C.R.S., N.F., M.S., D.L., M.S., J.T.N., S.B., D.W.). , Alexander M. BernhardtAlexander M. Bernhardt Department of Cardiovascular Surgery, University Heart Center Hamburg, Germany (A.M.B., H.R.). , Uwe ZeymerUwe Zeymer Heart Centre Ludwigshafen, Department of Cardiology, Germany (U.Z.). , Holger ThieleHolger Thiele Heart Centre Leipzig, University Hospital, Department of Internal Medicine/Cardiology, Germany (H.T.). , Hermann ReichenspurnerHermann Reichenspurner Department of Cardiovascular Surgery, University Heart Center Hamburg, Germany (A.M.B., H.R.). , Stefan BlankenbergStefan Blankenberg Department of General and Interventional Cardiology, University Heart Center Hamburg, Germany (P.M.B., C.R.S., N.F., M.S., C.W., D.L., M.S., J.T.N., S.B., R.T., D.W.). German Center for Cardiovascular Research, Partner Site Hamburg/Kiel/Lübeck (C.R.S., N.F., M.S., D.L., M.S., J.T.N., S.B., D.W.). , Raphael TwerenboldRaphael Twerenbold Department of General and Interventional Cardiology, University Heart Center Hamburg, Germany (P.M.B., C.R.S., N.F., M.S., C.W., D.L., M.S., J.T.N., S.B., R.T., D.W.). Cardiovascular Research Institute Basel and Department of Cardiology, University Hospital Basel, University of Basel, Switzerland (R.T.). and Dirk WestermannDirk Westermann Dirk Westermann, MD, University Heart Center Hamburg, Department of General and Interventional Cardiology, Martinistrasse 52, 20246 Hamburg, Germany. Email E-mail Address: [email protected] Department of General and Interventional Cardiology, University Heart Center Hamburg, Germany (P.M.B., C.R.S., N.F., M.S., C.W., D.L., M.S., J.T.N., S.B., R.T., D.W.). German Center for Cardiovascular Research, Partner Site Hamburg/Kiel/Lübeck (C.R.S., N.F., M.S., D.L., M.S., J.T.N., S.B., D.W.). Originally published12 Nov 2018https://doi.org/10.1161/CIRCULATIONAHA.118.036691Circulation. 2018;138:2298–2300Venoarterial extracorporeal membrane oxygenation (VA-ECMO) support is a lifesaving tool in cardiovascular care, providing excellent hemodynamic assistance for numerous indications, such as cardiogenic shock or periprocedural support in patients with acute heart failure.1 In addition, VA-ECMO evolved as a salvage therapeutic tool in cardiopulmonary resuscitation (CPR) situations refractory to medical treatment, with so-called extracorporeal CPR potentially improving outcome.2 Despite the increasing use of VA-ECMO support, the mortality of these patients is still high, and there are only a few randomized data demonstrating no clear benefit of this therapeutic option.3We aimed to analyze the incidence and outcome of all VA-ECMO procedures performed in Germany from 2007 to 2015 by using administrative data from the German Federal Health Monitoring System to investigate whether changes in incidence might influence in-hospital mortality.For the present analyses, all cases treated with VA-ECMO between 2007 and 2015 were identified and selected by the German Procedure Classification code for VA-ECMO (German Procedure Classification code 8852.3). To obtain data on coexisting conditions and outcomes, we used the available International Statistical Classification of Diseases and Related Health Problems, 10th Revision, German Modification and OPS codes. Individuals <18 years of age and patients with primary respiratory failure were excluded. Data on extracorporeal CPR were not separately available but were included in the overall group of prior CPR. The χ2 test was performed to compare categorical variables and the log-rank test to assess mortality between groups using SPSS Statistics (IBM SPSS version 23). No informed consent was needed for anonymous routine, governmental data collection, and data analyses did not require approval by an ethics committee. The primary prognostic end point was 30-day in-hospital mortality.Between 2007 and 2015, 8351 patients underwent VA-ECMO implantation for cardiopulmonary support. The annual number of VA-ECMO procedures steadily increased from 80 procedures in 2007 to 2614 procedures in 2015, more than a factor of 30, with the largest year-to-year increase in 2013 (Figure [A]). The mean age was 62 years, 71.7% were male patients, with prior CPR in 42.7%. Within the total cohort, the indication for VA-ECMO was acute coronary syndrome in 62.9%, acute heart failure in 35.2%, and graft failure after heart transplantation in 1.7%. In a comparison of trends over time between 2007 and 2015, patients undergoing VA-ECMO after 2012 were more likely to have major comorbidities than before, including atrial fibrillation (30.4% versus 38.9%, P<0.001), congestive heart failure (56.5% versus 65.8%, P<0.001), and chronic kidney disease (17.3% versus 23.7%, P<0.001). The proportion of patients undergoing VA-ECMO for the indication of acute heart failure slightly increased over time (27.6% versus 36.8%, P<0.001), resulting in decreased VA-ECMO implantations for acute coronary syndrome (70.5% versus 61.3%, P 1 procedure. B, Number of VA-ECMO procedures and 30-day in-hospital mortality stratified by age groups. Numbers represent procedures, not individual patients; some patients may have undergone >1 procedure. C, Kaplan-Meier unadjusted 30-day in-hospital mortality estimates with or without prior CPR and age <65 or ≥65 years undergoing VA-ECMO support. Time of follow-up was categorized in groups of 3 days. ACS indicates acute coronary syndrome; AHF, acute heart failure; and HTx, after heart transplantation.In the present cohort, overall 30-day in-hospital mortality was 61%. Thirty-day in-hospital mortality steadily increased with advanced age (Figure [B]). In survivors, the primary indication for VA-ECMO was more frequently acute heart failure (37.4% versus 33.8%, respectively; P<0.001), whereas acute coronary syndrome was less frequently observed than in nonsurvivors (58.5% versus 65.7%, respectively; P 65 years and the presence of prior CPR were identified as independent predictors of 30-day in-hospital mortality by multivariable Cox regression analysis.Patients ≤65 years with prior CPR had 30-day in-hospital mortality comparable to patients >65 years without prior CPR (65.4% versus 63.8%). In contrast, in patients without prior CPR and age ≤65 years, 30-day in-hospital mortality was 47.5% in comparison with 75.2% in patients with prior CPR and age >65 years (Figure [C]).Supported by our findings, VA-ECMO implementation has developed toward a routine procedure in Germany and has been used increasingly within the 9-year observational period. Despite the rapid increase of VA-ECMO use, 30-day in-hospital mortality remained rather unchanged over time (59.0% in 2007–2012 versus 61.4% in 2013–2015, P=0.942). The overall mortality observed in this analysis is in line with previous findings from comparable data sets of cardiogenic shock treated with VA-ECMO, reporting mortality rates between 24% and 64%.3,4 The growing incidence of VA-ECMO use, especially the sharp increase in 2013, could be explained by the rising doubts about the benefits of other percutaneous devices available for circulatory support, including the results of the IABP SHOCK II trial (Intraaortic balloon support for myocardial infarction with cardiogenic shock).5 Moreover, technological enhancements have led to the development of portable, miniaturized, and self-contained VA-ECMO systems. VA-ECMO support can act as a bridge-to-decision and bridge-to-treatment device. Hence, the increasing number of VA-ECMOs may reflect physicians' need for therapeutic options in patients with acute cardiopulmonary failure.The current study adds one of the largest data sets of VA-ECMO application to the literature, documenting an increase of VA-ECMO use by >30-fold between 2007 and 2015, whereas in-hospital mortality remained unaffected. Prior CPR and age >65 years were associated with higher mortality in patients undergoing VA-ECMO support.Data sharing:The data, analytic methods, and study materials will not be made available to other researchers for purposes of reproducing the results or replicating the procedure.DisclosuresThe authors designed the study, analyzed the data, vouch for the data and analysis provided by the Research Data Center of the Federal Bureau of Statistics in Wiesbaden, Germany, wrote the paper, and decided to publish. All authors have read and approved the manuscript. Dr Twerenbold received research support from the Swiss National Science Foundation (P300PB_167803), the University Hospital Basel, the University of Basel, and the Cardiovascular Research Foundation Basel, as well as speaker honoraria/consulting honoraria from Abbott, Brahms, Siemens, Singulex, and Roche. The other authors report no conflicts. Drs Westermann, Becher, and Twerenbold had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: Drs Becher, Twerenbold, and Westermann. Acquisition, analysis, or interpretation of data: Drs Becher, Twerenbold, and Westermann. Drafting of the manuscript: Drs Westermann, Becher, and Schmack. Critical revision of the manuscript for important intellectual content: all authors. Statistical analysis: Drs Becher, Twerenbold, and Westermann. Administrative, technical, or material support: Drs Schmack, Schwarzl, Fluschnik, Neumann, Waldeyer, Sinning, and Westermann.Footnotes*Drs Twerenbold and Westermann contributed equally.Data sharing: The data, analytic methods, and study materials will not be made available to other researchers for purposes of reproducing the results or replicating the procedure.https://www.ahajournals.org/journal/circDirk Westermann, MD, University Heart Center Hamburg, Department of General and Interventional Cardiology, Martinistrasse 52, 20246 Hamburg, Germany. Email d.[email protected]deReferences1. Lorusso R, Gelsomino S, Parise O, Mendiratta P, Prodhan P, Rycus P, MacLaren G, Brogan TV, Chen YS, Maessen J, Hou X, Thiagarajan RR. 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November 13, 2018Vol 138, Issue 20 Advertisement Article InformationMetrics © 2018 American Heart Association, Inc.https://doi.org/10.1161/CIRCULATIONAHA.118.036691PMID: 30571518 Originally publishedNovember 12, 2018 Keywordsacute coronary syndromecardiopulmonary resuscitationextracorporeal membrane oxygenationheart failurePDF download Advertisement SubjectsCardiopulmonary Resuscitation and Emergency Cardiac CareHeart FailureMortality/Survival
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