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Salvage from Extracorporeal Membrane Oxygenation due to Acute Deteriorated Heart Failure;Treatment Decision-tree Based on the Risk Factors Tomohiro Mizuno 1 , Tatsuki Fujiwara 1 , Hidehito Kuroki 1 , Kiyotoshi Oishi 1 , Toshihiro Kubo 1 , Keiji Oi 1 , Masafumi Yashima 1 , Seishi Takeshita 1 , Yushi Okumura 1 , Junya Nabeshima 1 , Hirokuni Arai 1 1Department of Cardiovascular Surgery, Tokyo Medical and Dental University Keyword: acute heart faillure , circulatory deterioration , extracorporeal membrane oxygenation , ventricular assist device pp.526-531
Published Date 2018/7/1
DOI https://doi.org/10.15106/j_kyobu71_526
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Background:Salvage rates for patients requiring extracorporeal membrane oxygenation (ECMO) due to acute cardiogenic shock remain poor due to difficulties in decision making on optical timing of ECMO removal or conversion to ventricular assist devices (VAD).

Method:From 2005 to 2018, 37 patients supported with ECMO due to acute circulatory deterioration were referred to our department for implantation of VAD. Their outcomes were analyzed using multi-variate analysis to assess the risk factors of VAD implantation, and we adopted a new decision-tree to improve the outcomes.

Results:Four patients had severe cerebral complications and 2 patients suffered severe infection. Those 6 patients were withdrawn from VAD implantation. ECMO could be removed in 6 patients, but one of them underwent VAD implantation due to the intraaortic balloon pumping (IABP) -dependent circulatory condition. In total, 25 patients underwent VAD implantation. Four patients reached to heart transplantation. Six patients remain on VAD. VAD was explanted due to recovery in 2 patients. Statistically significant risk factors by multi-variate analysis on 2-year mortality were preoperative necessity of renal replacement (p=0.006) and T-Bil (p=0.051, >4.0 mg/dl). Two-year survival of patients without end-organ dysfunction was 83.3%.However, 2-year survival of patients with end-organ dysfunction was miserable (23.1%). Based on these findings, we applied to a new decision-tree with 4 steps from 2016;①rule out strokes and sepsis, ②End-organ dysfunction should be treated before VAD implantation with proper management of mechanical circulatory support to recover end-organ dysfunction, ③urgent conversion to VAD if there is no aortic valve opening, ④conversion to VAD if cardiac functional recovery cannot be observed within 5 to 7 days. According to this decision-tree, 3 patients underwent VAD implantation after recovery from end-organ failure and survived in 2016.

Conclusions:Our experiences of salvage from ECMO in patients with severely impaired cardiac function suggest that end-organ dysfunction (necessity of renal replacement and T-Bil>4.0 mg/dl) was a strong risk factor for mid-term mortality. Those patients should undergo VAD implantation after recovery from end-organ dysfunction.


© Nankodo Co., Ltd., 2018

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電子版ISSN 2432-9436 印刷版ISSN 0021-5252 南江堂

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