Outcomes of ECMO use for post-cardiotomy cardiogenic shock.
Cardiogenic shock following cardiac surgery is rare, but a serious complication. Patients who suffer from severe valvular disease, low cardiac function, massive myocardial infarction, and acute aortic dissection have high risk of cardiogenic shock after surgery. Extracorporeal membrane oxygenation (ECMO) is a last resort treatment option for such patients. However, ethical concerns exist regarding whether ECMO is worthwhile for them, because it carries a huge financial burden, and the mortality of ECMO patients following cardiac surgery is reported to be as high as 60–80%. No guideline exists regarding optimal patient selection, duration of mechanical support, and management of ECMO. There are many unanswered questions in this field. This is a comprehensive review regarding the most recent available evidences in the field of ECMO support for post-cardiotomy cardiogenic shock.
- cardiac surgery
- cardiogenic shock
- extracorporeal membrane oxygenation support
Post-cardiotomy cardiogenic shock occurs in approximately 1% of adult cardiac surgical patients [1, 2]. For these patients, extracorporeal membrane oxygenation (ECMO) is a device for temporary mechanical circulatory support allowing cardiac and pulmonary recovery or as a bridge to further therapeutic alternatives.
However, the outcomes of ECMO use for post-cardiotomy patients are not satisfactory. Inhospital mortality has been reported to be as high as 60–85%. In addition, ECMO use requires blood products, manpower, and special resources; therefore, it is associated with a significant financial burden to the institution.
No clear guidelines exist regarding the management of ECMO after cardiac surgery. The decision to place a patient on ECMO after cardiac surgery is difficult. Physicians have to make a decision based on individual circumstances, considering the balance between risks and benefits of ECMO.
2. VA-ECMO for post-cardiotomy cardiogenic shock
2.1. Initiation of ECMO
The causes of cardiogenic shock following cardiac surgery are divided into three categories: reversible, potentially reversible, and irreversible . Reversible and potentially reversible causes of inability to wean from cardiopulmonary bypass include myocardial stunning, localized acute myocardial infarction, and acute pulmonary hypertension. Irreversible causes include pre-existing severe ventricular dysfunction, massive acute myocardial infarction, and chronic pulmonary hypertension.
ECMO offers the possibility of providing a bridge for maintaining organ perfusion and oxygenation allowing time for the heart and lung function to recover . Theoretically, ECMO is indicated for reversible or potentially reversible cardiogenic shock; however, it is hard to tell the reversibility of stunned or infarcted myocardium, and how long it would take for recovery.
2.2. ECMO set-up
ECMO following cardiac surgery is often established centrally, i.e., an arterial line through the ascending aorta and a venous line through the right atrium [5, 6]. If the chest is not open, or if there is a concern for leaving the chest open due to the risk of infection or bleeding, ECMO is established peripherally. This consists of a venous cannula in the femoral vein and an arterial cannula in the femoral artery.
If central ECMO is initiated, one can consider tunneling arterial and venous cannulas through the abdomen, so that the chest can be closed to reduce the risk of infection and bleeding .
2.3. Management of ECMO
ECMO management should be done in an intensive care unit, and perfusionists, cardiac surgeons, and intensivists should be involved.
Heparinization is a controversial issue in ECMO management. While anticoagulation is necessary to prevent formation of clots in the ECMO circuit, it increases the risk of bleeding from the cannulation sites and surgical fields . Ko et al. suggested avoiding use of heparin for the first 24 hours of ECMO support .
There is no consensus regarding anticoagulation management. Most centers use activated clotting time (ACT) to monitor the level of anticoagulation. ACT should be kept above 160 seconds during full flow of ECMO; whereas, it should be kept higher (>180 or >200 seconds) if patients have artificial valves or ECMO is in low flow . Blood transfusion is to be expected due to blood loss and coagulopathy. Some centers use thromboelastography to guide what blood products (platelets, fresh frozen plasma, or cryoprecipitate) are necessary during ECMO management .
2.4. Management of left ventricular distension
Left ventricular distension can happen as a result of inadequate drainage of the right atrium, shunting of blood between the bronchial and pulmonary artery circulation, and inadequate ejection of the left ventricle against the afterload posted by the ECMO. This can result in increased wall stress, increased myocardial oxygen consumption, pulmonary edema, and hemorrhage. There are some strategies to alleviate left ventricular distension .
Seib et al. described a technique of left heart decompression with blade and balloon atrial septostomy . They reported that this technique could successfully alleviate left atrial hypertension and pulmonary edema.
Aiyagari et al. described a technique of decompressing the left atrium by placing a transseptal left atrial drainage incorporated into the ECMO circuit . This drainage cannula can be placed via a patent foramen ovale . The left ventricle can be vented directly by placing a catheter percutaneously through the aortic valve into the left ventricle [18, 19].
Alternatively, other type of mechanical circulatory assist devices such as the Impella (Abiomed Inc., Danvers, MA) or the TandemHeart (CardiacAssist Inc., Pittsburgh, PA) can decompress the left ventricle .
2.5. Weaning of ECMO
The length of ECMO support ranges between 3 and 14 days . Fiser et al. suggested that consideration of discontinuing ECMO should be given after 48 to 72 hours of ECMO initiation, either by moving to an implantable ventricular assist device or by withdrawal of ECMO . Distelmaier et al. reviewed their experience of ECMO use in 354 patients, and found that prolonged ECMO support was associated with poor outcomes . They suggested reevaluation of therapeutic strategies after 7 days of ECMO, because mortality increases dramatically afterward.
A pulmonary artery catheter and transesophageal echocardiography are essential in weaning ECMO to assess the cardiac function. If a patient can successfully maintain a reasonable cardiac output on a low pump flow, ECMO can be discontinued.
The surgical outcomes of ECMO support for post-cardiotomy cardiogenic shock in adult patients are summarized in Table 1. Overall, about half of the patients could be weaned off ECMO; however, inhospital mortality was around 60–80%. In other words, only a quarter of the patients survived to be discharged home. Pokersnik et al. concluded that advancements in technology improved oxygenator durability, but had little impact on overall survival rates .
|Study||Number of pts||Successful weaning of ECMO||Survival|
|Rastan et al. ||517||63.3% was successfully weaned from ECMO||Inhospital mortality was 75.2%. Cumulative survivals were 17.6% after 6 months, 16.5% after 1 year, and 13.7% after 5 years.|
|Muehrcke et al. ||23||39.1% was weaned from ECMO, 13.0% underwent LVAD||Inhospital mortality was 69.6%.|
|Elsharkawy et al. ||233||12.0% was converted to implantable LVAD||Inhospital mortality was 64%.|
|Zhao et al. ||24||66.7% was weaned off ECMO||Inhospital mortality was 66.7%.|
|Ko et al. ||76||55.3% was weaned off ECMO, 2.6% underwent LVAD, and 2.6% underwent transplantation||Inhospital mortality was 73.7%.|
|Biancari et al. ||148||4.1% underwent LVAD||Inhospital mortality was 64.2%.|
One-, 2-, and 3-year survival was 31.0%, 27.9%, and 26.1%, respectively.
|Khorsandi et al. ||27||15% underwent short-term VAD implantation||Inhospital mortality was 59.3%.|
|Ariyaratnam et al. ||14||50% was weaned off ECMO||Inhospital mortality was 85.7%.|
|Smedira et al. ||202||23.8% underwent transplantation, 35.1% was weaned off ECMO||30-day mortality was 62%.|
Survival at 5 years was 24%.
|Bakhtiary et al. ||45||56% had successful weaning of ECMO||Inhospital mortality was 71%.|
During follow-up period up to 3 years, 22% were alive.
|Hsu et al. ||51||53% had successful weaning of ECMO||Inhospital mortality was 67%.|
29% patients were alive at 1-year postop.
|Li et al. ||123||56% had successful weaning of ECMO||Inhospital mortality was 65.9%.|
|Saxena et al. ||45||53% were weaned off ECMO||Inhospital mortality was 75.6%.|
|Papadopoulos et al. ||360||58% had successful weaning of ECMO||Inhospital mortality was 70%.|
|Unosawa et al. ||47||62% had successful weaning of ECMO||Inhospital mortality was 32%.|
The actuarial survival rates were 34.0% at 30 days, 29.8% at 1 year, and 17.6% at 10 years.
|Slottosch et al. ||77||62% had successful weaning of ECMO||30-day mortality was 70%.|
|Zhang et al. ||32||44% had successful weaning of ECMO||30-day mortality was 68.8%.|
At a follow-up period of 3.9 years, the overall survival rate was 12.5%.
|Doll et al. ||219||60% had successful weaning of ECMO||Inhospital mortality was 76%.|
Among survivors, 74% were alive at 5-year follow-up.
|Magovern et al. ||55||65% were weaned off ECMO||Inhospital mortality was 64%.|
|Pokersnik et al. ||49||55% were weaned off ECMO||Inhospital mortality was 67%.|
|Guihaire et al. ||92||48% were weaned off ECMO||Inhospital mortality was 63%.|
Overall 1-month and 6-month survival rates were, 42% and 39%, respectively.
Risk factors associated with hospital mortality were age [24, 26, 33, 35, 37, 40], diabetes [24, 26], obesity , female gender , pulmonary disease , atrial fibrillation , and chronic kidney disease [24, 28, 30, 34]. It is also suggested that the level of lactate [24, 28, 34, 35, 37, 38, 40], creatine kinase isoenzyme MB , longer duration of ECMO support [36, 37], mean lactate concentration , and lactate clearance  were predictors of inhospital mortality. In terms of surgical procedures, valvular surgery is generally associated with poor outcomes , and coronary artery bypass is associated with better outcomes .
Not many papers reported long-term outcomes after ECMO use for post-cardiotomy cardiogenic shock. One-year survival rate was around 20–30%. Despite high inhospital mortality, some papers reported the quality of life of survivors were acceptable with New York Heart Association functional class I or II [2, 9].
Biancari et al. performed a meta-analysis of the outcomes of ECMO for post-cardiotomy adult patients . They investigated 31 studies reported on 2986 patients who required post-cardiotomy ECMO. The weaning rate from ECMO was 59.5%, and hospital survival was 36.1%. One-year survival rate was 30.9%. However, there is a criticism for this paper, as it included post-transplant patients . Usually the outcomes of planned ECMO use following heart transplantation are better than those of unplanned non-transplant post-cardiotomy ECMO.
2.7. Complications of ECMO
ECMO is associated with high incidence of complications.
Major hemorrhage is the most commonly reported complication associated with ECMO institution. The reasons for excessive bleeding in ECMO patients are the surgical trauma, thrombocytopenia, activation of leukocytes, and necessity of anticoagulation. Rastan et al. reported that more than half of the patients required re-exploration of the chest for bleeding . Golding et al. reported that 87.3% required re-exploration for bleeding .
Cerebrovascular events also occurred frequently. Smedira et al. reported that 33% of the patients developed neurologic events , and Rastan et al. reported that the incidence of cerebrovascular events was 17.4% . The reasons for high incidence of cerebrovascular events include the operative procedure itself, hemodynamic instability, lack of pulsatile flow, retrograde perfusion via peripheral circuit, and anticoagulation-related injuries.
Leg ischemia is a complication specifically associated with peripheral ECMO institution . Rastan et al. reported that about 20% of the patients developed leg ischemia and 9.2% required leg fasciotomy . However, the risk of this complication can be reduced by using a distal leg perfusion cannula , or by using a dacron or hemashield prosthetic graft sewn onto the artery to maintain both central arterial blood flow as well as distal limb perfusion .
A meta-analysis performed by Biancari et al. reported that the rate of reoperation for bleeding was 42.9%, major neurological event 11.3%, lower limb ischemia 10.8%, deep sternal wound infection 14.7%, and renal replacement therapy 47.1% .
2.8. Bridge to alternatives
When patients have difficulty of being weaned from ECMO, physicians need to consider if they have to withdraw ECMO from them, or if they proceed to alternative options. Patients were more likely to be considered for bridging to heart transplantation if they are less than 60 years of age. Smedira et al. reported that 24% were bridged to heart transplantation . However, heart transplantation is not an available option in all countries.
Other options include left ventricular assist device (LVAD) or right ventricular assist device (RVAD). Muehrcke et al. reported that 4 out of 23 patients were transferred to an implantable LVAD from ECMO . Pokersnik et al. reported that 2 out of 49 patients were bridged to long-term devices—bi-ventricular assist devices .
2.9. Hospital transfer
Post-cardiotomy shock may happen at institutions which do not have much experience with the management of mechanical circulatory support devices. In addition, not all institutions have options of long-term devices such as LVAD, or transplantation. Therefore, the development of a robust program of tertiary referral is of paramount importance . Javidfar et al. reported no transport-related mortality or morbidity in patients who were transported via an ambulance with ECMO .
Teman et al. reported that patients with post-cardiotomy cardiac shock transported to a tertiary care center had a nearly 50% survival .
Weaning to recovery, institution of long-term support as a bridge to recovery, transition to transplantation or destination therapy, as well as device withdrawal and palliative care should be discussed in a multidisciplinary team including cardiologists, surgeons, intensivists, psychiatrists, and social workers .
The surgical mortality after ECMO use for post-cardiotomy cardiogenic shock remains high despite technological advancement. However, ECMO is the last resort to keep a patient alive who would otherwise expire on the operating table. According to the literatures, ECMO can be a salvage treatment in about one-third of these patients. Increased age, chronic kidney disease, and high level of lactate are major risk factors associated with hospital mortality. Also longer duration of ECMO support is associated with poor outcome. There is no guideline regarding optimal patient selection, duration of mechanical support, and management of ECMO.
A careful decision-making is necessary before ECMO is initiated, because ECMO is associated with a significant burden to a facility. As patients who need ECMO are always heterogeneous, the decision should be based on an individual basis.
A transfer to a tertiary center is critically important, because they can provide the transition to further supports, such as heart transplantation and implantable ventricular assist devices for patients who have difficulty of being weaned from ECMO.
Muehrcke DD, McCarthy PM, Stewart RW, Seshagiri S, Ogella DA, Foster RC, Cosgrove DM. Complications of extracorporeal life support systems using heparin-bound surfaces. The risk of intracardiac clot formation. The Journal of Thoracic and Cardiovascular Surgery. 1995; 110:843-851
Doll N, Kiaii B, Borger M, Bucerius J, Krämer K, Schmitt DV, Walther T, Mohr FW. Five-year results of 219 consecutive patients treated with extracorporeal membrane oxygenation for refractory postoperative cardiogenic shock. The Annals of Thoracic Surgery. 2004; 77:151-157
Ariyaratnam P, McLean LA, Cale AR, Loubani M. Extra-corporeal membrane oxygenation for the post-cardiotomy patient. Heart Failure Reviews. 2014; 19:717-725. DOI: 10.1007/s10741-014-9428-9
Bardia A, Schonberger RB. Postcardiotomy venoarterial extracorporeal membrane oxygenation (VA ECMO) in adult patients - Many questions, few answers, and hard choices. Journal of Cardiothoracic and Vascular Anesthesia. 2017 Oct 31. pii: S1053-0770(17)30821-2. DOI: 10.1053/j.jvca.2017.10.037
Khorsandi M, Dougherty S, Bouamra O, Pai V, Curry P, Tsui S, Clark S, Westaby S, Al-Attar N, Zamvar V. Extra-corporeal membrane oxygenation for refractory cardiogenic shock after adult cardiac surgery: A systematic review and meta-analysis. Journal of Cardiothoracic Surgery. 2017; 12:55. DOI: 10.1186/s13019-017-0618-0
Khorsandi M, Shaikhrezai K, Prasad S, Pessotto R, Walker W, Berg G, Zamvar V. Advanced mechanical circulatory support for post-cardiotomy cardiogenic shock: A 20-year outcome analysis in a non-transplant unit. Journal of Cardiothoracic Surgery. 2016; 11:29. DOI: 10.1186/s13019-016-0430-2
Kohler K, Valchanov K, Nias G, Vuylsteke A. ECMO cannula review. Perfusion. 2013; 28:114-124. DOI: 10.1177/0267659112468014
Muntean W. Coagulation and anticoagulation in extracorporeal membrane oxygenation. Artificial Organs. 1999; 23:979-983
Ko WJ, Lin CY, Chen RJ, Wang SS, Lin FY, Chen YS. Extracorporeal membrane oxygenation support for adult postcardiotomy cardiogenic shock. The Annals of Thoracic Surgery. 2002; 73:538-545
Magovern GJ Jr, Simpson KA. Extracorporeal membrane oxygenation for adult cardiac support: The Allegheny experience. The Annals of Thoracic Surgery. 1999; 68:655-661
Panigada M, Iapichino EG, Brioni M, Panarello G, Protti A, Grasselli G, Occhipinti G, Novembrino C, Consonni D, Arcadipane A, Gattinoni L, Pesenti A. Thromboelastography-based anticoagulation management during extracorporeal membrane oxygenation: A safety and feasibility pilot study. Annals of Intensive Care. 2018; 8:7. DOI: 10.1186/s13613-017-0352-8
Ranucci M, Ballotta A, Kandil H, Isgrò G, Carlucci C, Baryshnikova E, Pistuddi V. Surgical and clinical outcome research group. Bivalirudin-based versus conventional heparin anticoagulation for postcardiotomy extracorporeal membrane oxygenation. Critical Care. 2011; 15:275. DOI: 10.1186/cc10556
Pieri M, Agracheva N, Bonaveglio E, Greco T, De Bonis M, Covello RD, Zangrillo A, Pappalardo F. Bivalirudin versus heparin as an anticoagulant during extracorporeal membrane oxygenation: A case-control study. Journal of Cardiothoracic and Vascular Anesthesia. 2013; 27:30-34. DOI:10.1053/j.jvca.2012.07.019
Soleimani B, Pae WE. Management of left ventricular distension during peripheral extracorporeal membrane oxygenation for cardiogenic shock. Perfusion. 2012; 27:326-331. DOI: 10.1177/0267659112443722
Seib PM, Faulkner SC, Erickson CC, Van Devanter SH, Harrell JE, Fasules JW, Frazier EA, Morrow WR. Blade and balloon atrial septostomy for left heart decompression in patients with severe ventricular dysfunction on extracorporeal membrane oxygenation. Catheterization and Cardiovascular Interventions 1999; 46:179-186
Aiyagari RM, Rocchini AP, Remenapp RT, Graziano JN. Decompression of the left atrium during extracorporeal membrane oxygenation using a transseptal cannula incorporated into the circuit. Critical Care Medicine. 2006; 34:2603-2606
Madershahian N, Salehi-Gilani S, Naraghi H, Stoeger E, Wahlers T. Biventricular decompression by trans-septal positioning of venous ECMO cannula through patent foramen ovale. The Journal of Cardiovascular Surgery. 2011; 52:900
Fumagalli R, Bombino M, Borelli M, Rossi F, Colombo V, Osculati G, Ferrazzi P, Pesenti A, Gattinoni L. Percutaneous bridge to heart transplantation by venoarterial ECMO and transaortic left ventricular venting. The International Journal of Artificial Organs. 2004; 27:410-413
Barbone A, Malvindi PG, Ferrara P, Tarelli G. Left ventricle unloading by percutaneous pigtail during extracorporeal membrane oxygenation. Interactive Cardiovascular and Thoracic Surgery. 2011; 13:293-295. DOI: 10.1510/icvts.2011.269795
Cheng A, Swartz MF, Massey HT. Impella to unload the left ventricle during peripheral extracorporeal membrane oxygenation. ASAIO Journal. 2013; 59:533-536. DOI: 10.1097/MAT.0b013e31829f0e52
Sylvin EA, Stern DR, Goldstein DJ. Mechanical support for postcardiotomy cardiogenic shock: Has progress been made? Journal of Cardiac Surgery. 2010; 25:442-454. DOI: 10.1111/j.1540-8191.2010.01045.x
Fiser SM, Tribble CG, Kaza AK, Long SM, Zacour RK, Kern JA, Kron IL. When to discontinue extracorporeal membrane oxygenation for postcardiotomy support. The Annals of Thoracic Surgery. 2001; 71:210-214
Distelmaier K, Wiedemann D, Binder C, Haberl T, Zimpfer D, Heinz G, Koinig H, Felli A, Steinlechner B, Niessner A, Laufer G, Lang I, Goliasch G. Duration of extracorporeal membrane oxygenation support and survival in cardiovascular surgery patients. The Journal of Thoracic and Cardiovascular Surgery. 2017. pii: S0022-5223 (17)33057-X. DOI: 10.1016/j.jtcvs. 2017.12.079
Rastan AJ, Dege A, Mohr M, Doll N, Falk V, Walther T, Mohr FW. Early and late outcomes of 517 consecutive adult patients treated with extracorporeal membrane oxygenation for refractory postcardiotomy cardiogenic shock. The Journal of Thoracic and Cardiovascular Surgery. 2010; 139:302-311. DOI: 10.1016/j.jtcvs.2009.10.043
Muehrcke DD, McCarthy PM, Stewart RW, Foster RC, Ogella DA, Borsh JA, Cosgrove DM 3rd. Extracorporeal membrane oxygenation for postcardiotomy cardiogenic shock. The Annals of Thoracic Surgery 1996; 61:684-691
Elsharkawy HA, Li L, Esa WA, Sessler DI, Bashour CA. Outcome in patients who require venoarterial extracorporeal membrane oxygenation support after cardiac surgery. Journal of Cardiothoracic and Vascular Anesthesia. 2010; 24:946-951. DOI: 10.1053/j.jvca.2010.03.020
Zhao Y, Xing J, Du Z, Liu F, Jia M, Hou X. Extracorporeal cardiopulmonary resuscitation for adult patients who underwent post-cardiac surgery. European Journal of Medical Research. 2015; 20:83. DOI: 10.1186/s40001-015-0179-4
Biancari F, Dalén M, Perrotti A, Fiore A, Reichart D, Khodabandeh S, Gulbins H, Zipfel S,Al Shakaki M, Welp H, Vezzani A, Gherli T, Lommi J, Juvonen T, Svenarud P, Chocron S, Verhoye JP, Bounader K, Gatti G, Gabrielli M, Saccocci M, Kinnunen EM, Onorati F, Santarpino G, Alkhamees K, Ruggieri VG, Dell'Aquila AM. Venoarterial extracorporeal membrane oxygenation after coronary artery bypass grafting: Results of a multicenter study. International Journal of Cardiology. 2017; 241:109-114. DOI: 10.1016/j.ijcard.2017.03.120
Khorsandi M, Dougherty S, Sinclair A, Buchan K, MacLennan F, Bouamra O, Curry P, Zamvar V, Berg G, Al-Attar N. A 20-year multicentre outcome analysis of salvage mechanical circulatory support for refractory cardiogenic shock after cardiac surgery. Journal of Cardiothoracic Surgery. 2016; 11:151. DOI: 10.1186/s13019-016-0545-5
Smedira NG, Moazami N, Golding CM, McCarthy PM, Apperson-Hansen C, Blackstone EH, Cosgrove DM 3rd. Clinical experience with 202 adults receiving extracorporeal membrane oxygenation for cardiac failure: Survival at five years. The Journal of Thoracic and Cardiovascular Surgery 2001; 122:92-102
Bakhtiary F, Keller H, Dogan S, Dzemali O, Oezaslan F, Meininger D, Ackermann H, Zwissler B, Kleine P, Moritz A. Venoarterial extracorporeal membrane oxygenation for treatment of cardiogenic shock: Clinical experiences in 45 adult patients. The Journal of Thoracic and Cardiovascular Surgery. 2008; 135:382-388. DOI: 10.1016/j.jtcvs.2007.08.007
Hsu PS, Chen JL, Hong GJ, Tsai YT, Lin CY, Lee CY, Chen YG, Tsai CS. Extracorporeal membrane oxygenation for refractory cardiogenic shock after cardiac surgery: Predictors of early mortality and outcome from 51 adult patients. European Journal of Cardio-Thoracic Surgery. 2010; 37:328-333. DOI: 10.1016/j.ejcts.2009.07.033
Li CL, Wang H, Jia M, Ma N, Meng X, Hou XT. The early dynamic behavior of lactate is linked to mortality in postcardiotomy patients with extracorporeal membrane oxygenation support: A retrospective observational study. The Journal of Thoracic and Cardiovascular Surgery. 2015; 149:1445-1450. DOI: 10.1016/j.jtcvs.2014.11.052
Saxena P, Neal J, Joyce LD, Greason KL, Schaff HV, Guru P, Shi WY, Burkhart H, Li Z, Oliver WC, Pike RB, Haile DT, Schears GJ. Extracorporeal membrane oxygenation support in postcardiotomy elderly patients: The Mayo clinic experience. The Annals of Thoracic Surgery. 2015; 99:2053-2060. DOI: 10.1016/j.athoracsur.2014.11.075
Papadopoulos N, Marinos S, El-Sayed Ahmad A, Keller H, Meybohm P, Zacharowski K, Moritz A, Zierer A. Risk factors associated with adverse outcome following extracorporeal life support: Analysis from 360 consecutive patients. Perfusion. 2015; 30:284-290. DOI: 10.1177/0267659114542458
Unosawa S, Sezai A, Hata M, Nakata K, Yoshitake I, Wakui S, Kimura H, Takahashi K, Hata H, Shiono M. Long-term outcomes of patients undergoing extracorporeal membrane oxygenation for refractory postcardiotomy cardiogenic shock. Surgery Today. 2013; 43:264-270. DOI: 10.1007/s00595-012-0322-6
Slottosch I, Liakopoulos O, Kuhn E, Deppe AC, Scherner M, Madershahian N, Choi YH, Wahlers T. Outcomes after peripheral extracorporeal membrane oxygenation therapy for postcardiotomy cardiogenic shock: A single-center experience. The Journal of Surgical Research. 2013; 181:47-55. DOI: 10.1016/j.jss.2012.07.030
Zhang R, Kofidis T, Kamiya H, Shrestha M, Tessmann R, Haverich A, Klima U. Creatine kinase isoenzyme MB relative index as predictor of mortality on extracorporeal membrane oxygenation support for postcardiotomy cardiogenic shock in adult patients. European Journal of Cardio-Thoracic Surgery. 2006; 30:617-620
Pokersnik JA, Buda T, Bashour CA, Gonzalez-Stawinski GV. Have changes in ECMO technology impacted outcomes in adult patients developing postcardiotomy cardiogenic shock? Journal of Cardiac Surgery. 2012; 27:246-252. DOI: 10.1111/j.1540-8191.2011.01409.x
Guihaire J, Dang Van S, Rouze S, Rosier S, Roisne A, Langanay T, Corbineau H, Verhoye JP, Flécher E. Clinical outcomes in patients after extracorporeal membrane oxygenation support for post-cardiotomy cardiogenic shock: A single-centre experience of 92 cases. Interactive Cardiovascular and Thoracic Surgery. 2017; 25:363-369. DOI: 10.1093/icvts/ivx155
Biancari F, Perrotti A, Dalén M, Guerrieri M, Fiore A, Reichart D, Dell'Aquila AM, Gatti G, Ala-Kokko T, Kinnunen EM, Tauriainen T, Chocron S, Airaksinen JKE, Ruggieri VG, Brascia D. Meta-analysis of the outcome after postcardiotomy venoarterial extracorporeal membrane oxygenation in adult patients. Journal of Cardiothoracic and Vascular Anesthesia. 2017. pii: S1053-0770(17)30730-9. DOI: 10.1053/j.jvca.2017.08.048
Charlesworth M, Venkateswaran R, Barker JM, Feddy L. Postcardiotomy VA-ECMO for refractory cardiogenic shock. Journal of Cardiothoracic Surgery. 2017; 12:116. DOI: 10.1186/s13019-017-0674-5
Golding LA, Crouch RD, Stewart RW, Novoa R, Lytle BW, McCarthy PM, Taylor PC, Loop FD, Cosgrove DM 3rd. Postcardiotomy centrifugal mechanical ventricular support. The Annals of Thoracic Surgery 1992; 54:1059-1063
Bisdas T, Beutel G, Warnecke G, Hoeper MM, Kuehn C, Haverich A, Teebken OE. Vascular complications in patients undergoing femoral cannulation for extracorporeal membrane oxygenation support. The Annals of Thoracic Surgery. 2011; 92:626-631. DOI: 10.1016/j.athoracsur.2011.02.018
Fukuhara S, Takeda K, Garan AR, Kurlansky P, Hastie J, Naka Y, Takayama H. Contemporary mechanical circulatory support therapy for postcardiotomy shock. General Thoracic and Cardiovascular Surgery. 2016; 64:183-191. DOI: 10.1007/s11748-016-0625-4
Javidfar J, Brodie D, Takayama H, Mongero L, Zwischenberger J, Sonett J, Bacchetta M. Safe transport of critically ill adult patients on extracorporeal membrane oxygenation support to a regional extracorporeal membrane oxygenation center. ASAIO Journal. 2011; 57:421-425. DOI: 10.1097/MAT.0b013e3182238b55
Teman NR, Demos DS, Reames BN, Pagani FD, Haft JW. Outcomes after transfer to a tertiary center for postcardiotomy cardiopulmonary failure. The Annals of Thoracic Surgery. 2014; 98:84-89. DOI: 10.1016/j.athoracsur.2013.12.091