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

From: Extra-corporeal membrane oxygenation for refractory cardiogenic shock after adult cardiac surgery: a systematic review and meta-analysis

Author (year published) & country Historical period Number of patients & Indications for surgery Outcomes with key results Comments
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 CentriMagR 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
  1. Abbreviations: ECMO Extra-corporeal membrane oxygenator, CABG coronary artery bypass grafting, IABP Intra-aortic balloon pump, LVAD Left ventricular assist device, RVAD Right ventricular assist device, BiVAD Biventricular assist device, NYHA New York Heart Association, MODS Multi-organ dysfunction syndrome, VA veno-arterial, GI gastrointestinal, AVR aortic valve replacement, MVR Mitral valve replacement, CI cardiac index, CPB Cardiopulmonary bypass, AS aortic stenosis, MI Myocardial infarction, LMS left main stem coronary artery, PVD peripheral vascular disease
  2. PCCS Post cardiotomy cardiogenic shock, ICU intensive care unit, LV left ventricle, RV right ventricle, RRT renal replacement therapy, Pts patients, OHT orthotopic heart transplantation, CHD congenital heart disease, MV mitral valve, MVR mitral valve replacement, TV tricuspid valve, TVR tricuspid valve replacement