Table 1 Summary of outcomes of studies examining patients with PCCS treated with VA-ECMO

Khorsandi et al. [29] (2015), United Kingdom

4/1995–4/2015

15 patients

-AVR (n = 3)

-CABG (n = 3)

-CABG & AVR (n = 1)

-Aortic dissection/transection (n = 3)

-MV repair/MVR & CABG (n = 2)

-Miscellaneous (n = 3)

Age range: 34–83 years (median 71)

30-day survival: 37.5%

Survival to hospital discharge: 31.25%

24-month survival: 31.25

Functional status: NYHA status I-II

Authors reported acceptable functional outcome post VA-ECMO

Weaknesses: limited sample size; retrospective study

Doll et al. [13] (2004), Germany

11/1997–7/2002

219 patients

-CABG (n = 119)

-CABG & AVR (n = 240)

-MVR (n = 110

-Other (n = 44)

Average age: 61.3 years +/− 12.1

Mean period on ECMO: 2.8 +/− 2.2 days

Weaned from ECMO: 61% (n = 133)

30-day mortality: 76% (n = 167)

Discharged from hospital after 29 +/− 24 days: 39% (n = 52)

5-year follow-up: 74% (n = 37) were alive

Authors concluded that VA-ECMO is an acceptable life-saving measure in high-risk patients with refractory PCCS

Weaknesses: limited study size; retrospective study

Khorsandi et al. [20] (2016), United Kingdom

4/1995–4/2015

23 patients

-AVR (n = 8)

-CABG (n = 6)

-CABG & AVR (n = 2)

-Aortic dissection/transection (n = 4)

-MVR/MV repair & CABG (n = 3)

Age range: 34–83 years (median 51)

30-day survival: 39% (n = 9)

Survival to hospital discharge: 35% (n = 8)

12-month follow up: 100% survival

Functional status: NYHA I-II

Authors concluded that VA-ECMO has a high rate of systemic and device-related complications with a definite survival benefit

Rastan et al. [5] (2010), Germany

5/1996–5/2008

516 patients:

-CABG (37.4%)

-CABG & AVR (16.6%)

-AVR (14.3%)

-Heart/lung transplant (6.5%)

-Other (25%)

Age range: 18–84 years (mean 63.5)

Mean ECMO duration: 3.28 days +/− 2.85

Weaned from ECMO: 63.3%

Discharged home: 24.8%

Complications: 65% renal complications; 58% major bleeding requiring re-intervention; 17.4% stroke; 18% GI complications

Authors concluded that VA-ECMO is an acceptable treatment for refractory PCCS in those patients that would otherwise die

Weaknesses: limited sample size; retrospective study

Slottosch et al. [21] (2013), Germany

2006–2010

77 patients:

-CABG (n = 43)

-Valve (n = 10)

-CABG & Valve (n = 11)

-Aortic surgery (n = 5)

-Heart transplant (n = 2)

-Other (n = 6)

Mean age: 60 years +/− 13

Weaned from ECMO: 62%

30-day mortality: 70%

Predictors of mortality: advanced age (p = 0.003); rising serum lactate, prolonged ECMO course and ECMO-GI complications were independent predictors of 30-day mortality (p < 0.05)

Complications of ECMO: limb ischaemia (20.8%), renal failure (68.8%), & reopening for bleeding (29.9%)

High-quality study

No long-term follow-up outcomes included

Needs long-term quality of life assessment

Hsu et al. [38] (2010), Taiwan

1/2001–12/2006

51 patients:

-CABG (n = 27)

-Valve surgery (n = 11)

-CABG & valve (n = 7)

-Heart transplant (n = 4)

-Other (n = 2)

Average age: 63 years +/− 15.7

Mean duration of ECMO: 7.5 days +/− 6.7

30-day mortality: 49%

3-month mortality: 65%

1-year mortality: 71%

Authors concluded that VA-ECMO provides good support post PCCS

Study weaknesses: small sample size; longer-term follow-up required; quality of life assessment not included

Ko et al. [19] (2002), Taiwan

8/1994–5/2000

76 patients:

-CABG (n = 37)

-CABG a & valve (n = 6)

-Isolated valve (n = 14)

-Heart transplant (n = 12)

-Congenital surgery (n = 3)

-LVAD (N = 2)

-Aortic surgery (n = 2)

Mean age: 56.8 years +/− 15.9

Weaned from ECMO: 60.5% (n = 46)

Survival to hospital discharge: 26.3% (n = 20)

Functional status: all survivors NYHA I-II on follow-up period of 33+/−22 months

Strengths: good intermediate-term follow-up

Weaknesses: small sample size

Muehrcke et al. [3] (1996), USA

9/1992–7/1994

22 patients:

-CABG (n = 8)

-Valve (n = 6)

-Heart transplant (n = 4)

-Post-infarction VSD (n = 2)

-Miscellaneous (n = 2)

Average age: 47.3 years +/− 16.4 (range 5–72)

Weaned from ECMO: 30.4% (n = 7)

Subsequent heart transplant: 13.6% (n = 3)

Complications: major haemorrhage, leg ischaemia, renal failure, thrombus formation, and stroke

Weaknesses: limited sample size, no long-term follow-up data

Santarpino et al. [14] (2015), multicenter European study

2005–2015

20 patients, from 11 European centers

-CABG (n = 85)

Average age: 64.6 years +/− 10.3

Survival to hospital discharge: 40% (n = 8)

1-year survival: 29.3%

Complications: stroke (40%), reopening for bleeding (60%), dialysis for renal failure (35%), DSWI (30%)

Salvage CABG has high rate of immediate mortality

ECMO for refractory PCCS has encouraging results

Saeed et al. [39] (2015), Germany

1/2013–7/2014

9 patients:

-CABG & valve replacement (n = 5)

-CABG (n = 4)

Average age: 65 years +/− 14

Weaned from ECMO: 44% (n = 4)

Survival to hospital discharge: 22% (n = 2)

Complications: renal failure (89%, n = 8)

Weaknesses: small sample size

Sajjad et al. [40] (2012), Saudi Arabia

1/2007–12/2009

19 patients:

- Emergency (n = 11)

-Urgently (n = 5)

-Electively (n = 3)

Age range: 21–79 years (mean 55.6)

Unable to wean (died on ECMO): 63% (n = 12)

30-day mortality: 94.7%

Survival to hospital discharge: 5.3%

Authors concluded that ECMO is costly, prolongs ICU stay and delays imminent death in most patients

Mikus et al. [22] (2013), Italy

2007–2014

14 patients:

-AVR and/or MVR (n = 6)

-CABG (n = 6)

-Bentall procedure (n = 3)

Mean age: 53.1 years +/− 14.3 (range 25–70)

Successful weaning: 50% (n = 7)

Survival to hospital discharge: 42.8% (n = 6)

Complications: mediastinal bleeding (64.3%), renal failure (50%), sepsis (42.8%), pneumonia (28.6%)

Authors concluded that VA-ECMO with Levitronix CentriMag^R is a reliable and easy to apply life-saving mechanical support which can be applied to bridge postcardiotomy patients to decision

Unosawa et al. [27] (2013), Japan

04/1992–06/2007

47 patients:

-CABG (n = 19)

-Valve (n = 8)

-CABG & Valve (n = 2)

-Aortic surgery (n = 5)

-Valve & aortic surgery (n = 1)

-Aortic surgery & CABG (n = 3)

-Aortic root replacement (n = 2)

-Post-infarction VSD (n = 5)

Pulmonary embolectomy (n = 2)

Average age: 64.4 years +/− 12.5 (range 22–83)

Weaned from ECMO: 60.7% (n = 29)

Survival to hospital discharge: 48% (n = 14)

30-day survival: 34%

1-year survival: 29.8%

10-year survival: 17.6%

Independent risk factors for mortality: incomplete sternal closure (p = 0.049) and ECMO duration >48 h (p = 0.027)

Authors concluded that VA-ECMO for refractory PCCS is associated with high morbidly and mortality but that survivors have acceptable long-term survival

Strengths: long follow-up period

Pokersnik et al. [41] (2012), USA

01/2005–12/2010

49 patients. Group 1 (n = 11): Biomedicus pump with an affinity oxygenator

Group 2 (n = 11): Biomedicus pump with a Quadrox D oxygenator

Group 3 (n = 27): Rotaflow pump with a Quadrox D oxygenator

Average age: 65 years +/− 13

Weaned from ECMO:

-Group 1: 63.6%

-Group 2: 45.5%

-Group 3: 55.6%

In-hospital survival:

-Group 1: 27.3%

-Group 2: 27.3%

-Group 3: 33.3%

Authors concluded that outcomes for patients undergoing ECMO for PCCS remain poor in all categories

Moreno et al. [42] (2011), Spain

11/2006–12/2009

12 patients

-Cardiac surgery (n = 8)

-Heart transplant (n = 4)

Mean age: 56.8 years (standard deviation 9.1)

Mean duration on ECMO: 5.4 days

Survival to hospital discharge: 50%

Authors concluded that VA-ECMO provided viable temporary circulatory support

Wu et al. [17] (2010), Taiwan

2003–2009

110 patients:

-CABG (n = 31)

-Valve (n = 16)

-Multiple valves (n = 26)

-Combined valve and other (n = 19)

-Aortic surgery (n = 8)

-Post-infarction VSD (n = 3)

-Pulmonary endarterectomy (n = 4)

OHT (n = 3)

Average age: 60 years +/− 14

Weaned from ECMO: 61% (n = 67)

Survival to hospital discharge: 42% (n = 46)

Adverse prognostic indicators: age > 60 years, renal failure, serum bilirubin >6 mg/dL, and duration of ECMO >110 h; persistent heart failure (EF <60%) was a predictor of mortality after hospital discharge

Authors concluded that VA-ECMO has a definite survival benefit

Strengths: adverse prognostic indicators were reported

Elsharkawy et al. [16] (2010), USA

1/1995–12/2005

233 patients:

-CABG (n = 86)

-Any valve (n = 69)

-AVR/repair (n = 42)

-MV repair/MVR (n = 44)

-TV repair/TVR (n = 16)

Survivors’ IQR: 45.1–61.4 (median 53.5)

Non-survivors’ IQR: 52.1–66.3 (median 59.7)

Survival to hospital discharge: 36%

Associated with higher mortality rate: older age, known diabetes, CABG, longer CPB time

Associated with reduced hospital morality: younger age

Authors concluded that patient selection for salvage VA-ECMO for refractory PCCS remains difficult as the variables identified in the study are not easily modifiable and do not appear to be “robust”

Bakhtiary et al. [18] (2008), Germany

1/2003–11/2006

45 patients:

-CABG (n = 20)

-LVAD (n = 5)

-OHT (n = 1)

-CABG & Post-infarction VSD (n = 3)

-CABG & MV repair (n = 5)

-AVR (n = 2)

-CABG & AVR (n = 3)

-Miscellaneous (n = 5)

Average age: 60.1 years +/− 13.6

Weaned from ECMO: 55% (n = 25)

30-day mortality: 55% (n = 25)

In-hospital morality: 71% (n = 32)

Survival to hospital discharge: 29% (n = 13)

3-year survival: 77% (n = 10) with NYHA class II (n = 6), NYHA class IV (n = 4)

Improved survival: absence of pulmonary hypertension and use of IABP (p = 0.04)

Authors concluded that VA-ECMO provides sufficient cardiopulmonary support. Peripheral cannulation techniques and reduced anticoagulation could reduce bleeding rates

Doll et al. [8] (2003), Germany

11/1997–02/2000

95 patients:

-CABG (n = 63)

-AVR (n = 16)

-CABG & AVR (n = 8)

-Others (n = 8)

Average age: 59.8 years +/− 13.3

Weaned from ECMO: 47% (n = 45)

Survival to hospital discharge: 29% (n = 28)

Mortality rates for CABG & AVR on ECMO: 100% (p < 0.05)

Complications: renal failure (64%), re-exploration for haemorrhage (62%), & limb ischaemia (16%)

Authors concluded that “short term” ECMO support is a suitable technique for short-term low cardiac out states

Wang et al. [43] (1996), Taiwan

10/1994–10/1995

18 patients:

-CABG (N = 7)

-CABG & Valve (n = 3)

-OHT (n = 3)

-Valve (n = 2)

-Miscellaneous (n = 3)

Average age: 46.5 years +/− 24.6

Weaned from ECMO: 52.6% (n = 10)

Survival to hospital discharge: 33% (n = 6) in “good condition”

Complications: leg ischaemia (n = 3), bleeding (n = 4), renal failure (n = 3), and tube rupture (n = 1)

One patient received 2 runs of ECMO

This cohort included routine adult cardiac surgery as well as heart transplants

Magovern et al. [44] (1994), USA

10/1991–10/1993

21 patients

Divided into 3 categories:

-Cat 1: after CABG (n = 14)

-Cat 2: MV surgery (n = 3)

-Cat 3: after open heart surgery & prolonged CPR (n = 4)

Mean age: 61.6 years +/− 2.2 (33–78)

Survival to hospital discharge:

-Cat 1: 80% (0% for both categories 2 & 3)

-Total survival to hospital discharge: 52%

Complications: stroke, renal failure, and mediastinitis

Authors commented that VA-ECMO in the context of MV surgery does not decompress the LV (where there is often concurrent LV distension), thus is not effective

Saxena et al. [45] (2015), USA

2003–2013

45 patients Additional inclusion criteria: age > 70 years:

-Valve repair/replacement (n = 16)

-Valve & CABG (n = 13)

-Other (n = 16)

Mean age: 76.8 years +/− 4.6

Mortality whilst on ECMO: 46.6% (n = 21)

Weaned from ECMO: 53.3% (n = 24)

Survival to hospital discharge: 24% (n = 11)

Complications: renal failure 44.4% (n = 30), pneumonia 26.7% [12], & sepsis 24.4% (n = 11)

Adverse prognostic indicators: preoperative AF, CKD, lactic acidosis on ECMO, persistent coagulopathy

Total 47 runs of ECMO (two patients each received two runs)

Authors concluded that VA-ECMO for PCCS confers high morbidity & mortality rates. However, it provides a last line of support for patients that would otherwise die

Li et al. [15] (2015), China

01/2011–12/2012

123 patients:

-CABG (n = 44)

-CABG & other (n = 15)

-Valve (n = 40)

-OHT (n = 11)

-Other (n = 13)

Mean age: 56.2 years +/− 11.8 (range 18–76)

Weaned from ECMO: 56%

Survival to hospital discharge: 34.1%

Predictors of in-hospital mortality: advanced age, female sex, elevated mean lactate and lactate clearance (p < 0.05)

Yan et al. [46] (2010), China

2004–2008

67 patients:

-CABG +/− Valve (n = 49)

-OHT (n = 9)

-Adult CHD (n = 5)

-Other (n = 5)

Average age: 50.5 years +/− 13.6

Survival to hospital discharge: 49%

Prognostic indicators: mortality was much higher amongst patients who received RRT than those that did not (73% vs 32%, p = 0.001)

Authors concluded that renal failure is a major ECMO-related complication after PPCS and is associated with a significant mortality rate