Urgent ECMO after cardiogenic shock admission could lower mortality
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Key takeaways:
- Delayed ECMO initiation was tied to increased in-hospital mortality among patients with cardiogenic shock.
- ECMO within 24 hours may reduce mortality, even among those admitted with less acute illness.
Delayed extracorporeal membrane oxygenation after hospital admission with cardiogenic shock was associated with increased in-hospital mortality, even among less acutely ill patients, researchers reported.
“Despite the array of temporary mechanical circulatory support devices developed to improve hemodynamics in patients with cardiogenic shock, none been proven to improve survival in cardiogenic shock populations. Among the common temporary mechanical circulatory support devices, the venoarterial extracorporeal membrane oxygenator has been increasingly used because of its ability to provide full biventricular plus pulmonary support at the bedside using easily deployed equipment,” Jacob C. Jentzer, MD, a cardiac intensivist at Mayo Clinic in Rochester, Minnesota, and colleagues wrote. “The severity of cardiogenic shock can influence the urgency of extracorporeal membrane oxygenation (ECMO) initiation, as can the availability of the necessary equipment and staff. Therefore, we sought to understand the association between the timing of ECMO initiation and outcomes in patients with cardiogenic shock.”
Image: Adobe Stock
For this retrospective analysis of data from the Extracorporeal Life Support Organization (ELSO) registry, Jentzer and colleagues identified 8,619 patients with cardiogenic shock who received venoarterial ECMO, excluding those cannulated following an operation (median age, 57 years; 33.5% women).
The median duration from admission to ECMO was 14 hours, with 68.2% of the cohort initiated within 24 hours, including 44.2% within 12 hours.
The results were published in the Journal of the American Heart Association.
Patients who received ECMO within 24 hours were more often younger with more acute MI, more preceding cardiac arrest and more acidosis, compared with those who initiated ECMO after 24 hours.
After adjustment, Jantzer and colleagues reported that ECMO initiation more than 24 hours after admission was associated with greater risk for in-hospital death (adjusted OR = 1.2; 95% CI, 1.06-1.36; P = .004), with every 12-hour increase in the time from admission to ECMO associated with an OR of 1.06 for in-hospital mortality (95% CI, 1.03-1.1; P < .001).
Moreover, the association between longer time to ECMO after admission and in-hospital mortality was especially strong in patients with Society for Cardiovascular Angiography and Interventions shock stage B (P = .02).
“We observed an incremental association between admission-to-ECMO time and a higher in-hospital mortality rate. This effect was observed whether time was analyzed on a per-hour, 12-hour or daily basis,” the researchers wrote. “Interestingly, the relationship between time to ECMO and death was observed primarily within the subgroup that was less acutely ill at ECMO cannulation, such as those who did not receive any other forms of mechanical circulatory support before ECMO.
“Given that the recent ECMO-CS trial failed show a significant benefit to early ECMO among patients with severe or refractory cardiogenic shock, our results provide further evidence that the benefit of early ECMO for acute cardiogenic shock may be among patients who are less acutely ill,” they wrote. “Our findings could suggest that prompt mechanical circulatory support (including ECMO) could play a key role in death reduction for medical cardiogenic shock.”
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