Predictors of in-hospital mortality and midterm outcomes of patients successfully weaned from venoarterial extracorporeal membrane oxygenation.

OBJECTIVES: There is limited evidence to guide the decision to proceed with weaning from venoarterial extracorporeal membrane oxygenation, and approximately 30% of patients weaned "successfully" do not survive to hospital discharge. We evaluated predictors of in-hospital mortality and midterm outcomes of patients successfully weaned from venoarterial extracorporeal membrane oxygenation after support for cardiogenic shock, surviving more than 24 hours after weaning, with the aim of improving patient selection for durable weaning. METHODS: We performed a retrospective analysis of 92 patients supported on venoarterial extracorporeal membrane oxygenation and successfully weaned between January 2013 and February 2018. Survival was estimated by the Kaplan-Meier method. Predictors of in-hospital mortality were identified using a Cox proportional hazards model and an Akaike information criterion-selected multivariate model. RESULTS: Overall survival at hospital discharge was 64.2%; survival was 54.6% 1 year after support and 51.4% 3 years after support. A history of diabetes, previous myocardial infarction, prolonged extracorporeal membrane oxygenation support, and hypoxemia at extracorporeal membrane oxygenation weaning were independent predictors of in-hospital mortality. At midterm follow-up, New York Heart Association class I heart function was observed in 53% of patients, class II in 19%, class III in 16%, and class IV in 12%. Average left ventricular ejection fraction was 46.5% ± 18.2%, and 50% of the patients had been readmitted to the hospital because of heart failure. CONCLUSIONS: Durable extracorporeal membrane oxygenation weaning with acceptable midterm functional status is obtainable in well-selected patients. Previous myocardial infarction, diabetes, prolonged extracorporeal membrane oxygenation support, and pulmonary dysfunction strongly predicted in-hospital mortality after venoarterial extracorporeal membrane oxygenation weaning. In this high-risk situation, other heart replacement therapies should be considered.

Mid-term outcomes with the use of extracorporeal membrane oxygenation for cardiopulmonary failure secondary to massive pulmonary embolism.

OBJECTIVES: There has been increasing interest in using extracorporeal membrane oxygenation (ECMO) to rescue patients with pulmonary embolism (PE) in the advanced stages of respiratory or haemodynamic decompensation. We examined mid-term outcomes and risk factors for in-hospital mortality. METHODS: We conducted a retrospective study of 36 patients who required ECMO placement (32 veno-arterial ECMO, 4 veno-venous) following acute PE. Survival curves were estimated using the Kaplan-Meier method. Risk factors for in-hospital mortality were assessed by logistic regression analysis. Functional status and quality of life were assessed by phone questionnaire. RESULTS: Overall survival to hospital discharge was 44.4% (16/36). Two-year survival conditional to discharge was 94% (15/16). Two-year survival after veno-arterial ECMO was 39% (13/32). In patients supported with veno-venous ECMO, survival to discharge was 50%, and both patients were alive at follow-up. In univariable analysis, a history of recent surgery (P = 0.064), low left ventricular ejection fraction (P = 0.029), right ventricular dysfunction ≥ moderate at weaning (P = 0.083), on-going cardiopulmonary resuscitation at ECMO placement (P = 0.053) and elevated lactate at weaning (P = 0.002) were risk factors for in-hospital mortality. In multivariable analysis, recent surgery (P = 0.018) and low left ventricular ejection fraction at weaning (P = 0.013) were independent factors associated with in-hospital mortality. At a median follow-up of 23 months, 10 patients responded to our phone survey; all had acceptable functional status and quality of life. CONCLUSIONS: Massive acute PE requiring ECMO support is associated with high early mortality, but patients surviving to hospital discharge have excellent mid-term outcomes with acceptable functional status and quality of life. ECMO can provide a stable platform to administer other intervention with the potential to improve outcomes. Risk factors for in-hospital mortality after PE and veno-arterial ECMO support were identified.

Not All Septal Defects Are Equal: Outcomes of Bilateral Lung Transplant With Cardiac Defect Repair vs Combined Heart-Lung Transplant in Patients With Eisenmenger Syndrome in the United States.

BACKGROUND: Thoracic transplantation is considered for patients with Eisenmenger syndrome (ES) who have refractory right ventricular failure despite optimal therapy for pulmonary arterial hypertension. This study compared the outcomes of bilateral lung transplantation (BLT) with cardiac defect repair vs combined heart-lung transplantation (HLT). RESEARCH QUESTION: This study presents an updated analysis using a US national registry to evaluate the outcomes of patients diagnosed with ES who underwent HLT or BLT with repair of cardiac defects. STUDY DESIGN AND METHODS: This study identified patients with ES who underwent thoracic transplantation from 1987 to 2018 from the United Network for Organ Sharing database. Survival curves were estimated by using the Kaplan-Meier method and were compared by using the log-rank test. RESULTS: During the study period, 442 adults with ES underwent thoracic transplantation (316 HLTs and 126 BLTs). Following BLT, overall survival 1, 5, and 10 years' posttransplant was 63.1%, 38.5%, and 30.2%, respectively. Following HLT, overall survival 1, 5, and 10 years' posttransplant was 68.0%, 47.3%, and 30.5% (P = .6). When survival analysis was stratified according to type of defect, patients with an atrial septal defect had better survival following BLT than following HLT (88.3% vs 63.2% 1 year posttransplant, P < .01; 71.1% vs 49.8% 3 years' posttransplant, P < .01; and 37.4% vs 29.9% 10 years' posttransplant, P = .08). Patients with a ventricular septal defect (VSD) exhibited better survival following HLT than following BLT (78.2% vs 49.6% 1 year posttransplant, P < .01; 55.6% vs 34.3% 5 years' posttransplant, P < .01; and 35.7% vs 26.5% 10 years' posttransplant, P = .03). The most common cause of mortality in patients with VSD undergoing BLT was cardiac ventricular failure. INTERPRETATION: This study suggests that the best transplant option for patients with VSD remains HLT, which prevents subsequent development of ventricular failure. BLT with cardiac defect repair should be considered as the first-line treatment option in patients with ES due to an uncorrected atrial septal defect. These patients can be considered to have isolated and reversible right ventricular failure akin to patients with advanced pulmonary arterial hypertension.