Selzman, Craig H.

Background Venoarterial extracorporeal membrane oxygenation (ECMO) provides full hemodynamic support for patients with cardiogenic shock, but optimal timing of ECMO initiation remains uncertain. We sought to determine whether earlier initiation of ECMO is associated with improved survival in cardiogenic shock. Methods and Results We analyzed adult patients with cardiogenic shock who received venoarterial ECMO from the international Extracorporeal Life Support Organization (ELSO) registry from 2009 to 2019, excluding those cannulated following an operation. Multivariable logistic regression evaluated the association between time from admission to ECMO initiation and in‐hospital death. Among 8619 patients (median, 56.7 [range, 44.8–65.6] years; 33.5% women), the median duration from admission to ECMO initiation was 14 (5–32) hours. Patients who had ECMO initiated within 24 hours (n=5882 [68.2%]) differed from those who had ECMO initiated after 24 hours, with younger age, more preceding cardiac arrest, and worse acidosis. After multivariable adjustment, patients with ECMO initiated >24 hours after admission had higher risk of in‐hospital death (adjusted odds ratio, 1.20 [95% CI, 1.06–1.36]; P =0.004). Each 12‐hour increase in the time from admission to ECMO initiation was incrementally associated with higher adjusted in‐hospital mortality rate (adjusted odds ratio, 1.06 [95% CI, 1.03–1.10]; P <0.001). The association between longer time to ECMO and worse outcomes appeared stronger in patients with lower shock severity. Conclusions Longer delays from admission to ECMO initiation were associated with higher a mortality rate in a large‐scale, international registry. Our analysis supports optimization of door‐to‐support time and the avoidance of inappropriately delayed ECMO initiation.

Introduction: Venoarterial extracorporeal membrane oxygenation (VA ECMO) provides full hemodynamic support for cardiogenic shock (CS), but optimal timing of ECMO initiation remains uncertain. Hypothesis: We hypothesized that earlier initiation of ECMO would be associated with improved survival in CS patients. Methods: We analyzed adult patients with CS who received VA ECMO from the Extracorporeal Life Support Organization (ELSO) Registry from 2009 - 2019, excluding those cannulated following an operation. Multivariable logistic regression evaluated the association between time from admission to ECMO initiation and in-hospital mortality. Results: Among 8619 patients (median 56.7 years; 33.5% females), the duration from admission to ECMO initiation was 14 (5, 32) hours. Patients who had ECMO initiated within 24 hours (n = 5882 [68.2%]) differed from those who had ECMO initiated after 24 hours, with younger age, more preceding cardiac arrest, and worse acidosis. After adjustment, patients with ECMO initiated more than 24 hours after admission had higher risk of adjusted in-hospital mortality (adjusted OR 1.20, 95% CI 1.06-1.36, p = 0.004) (Figure 1). Each 12-hour increase in the time from admission to ECMO initiation was incrementally associated with higher adjusted in-hospital mortality (adjusted OR 1.06, 95% CI 1.03-1.10, p < 0.001). The association between longer time to ECMO and worse outcomes appeared stronger in patients with lower shock severity. Among patients who were cannulated within 24 hours, those cannulated during the same day shift had lower mortality than those who were admitted at night and cannulated the following day (adjusted OR adjusted OR 0.81, 95% CI 0.66-0.99, p = 0.04). Conclusions: Longer delays from admission to ECMO initiation were associated with higher mortality in a large-scale, international registry. Our analysis supports optimization of door-to-support time and the avoidance of inappropriately delayed ECMO initiation.

The Jarvik 2000 bridge to transplant investigational device exemption study was a multicentered, prospective study of 150 UNOS status I patients implanted with the Jarvik 2000 between 2005 and 2012. During the study period, there were numerous modifications of the system that included converting from pin to cone bearings. Results were analyzed for three cohorts: total (n = 150), pin (n = 128), and cone (n = 22). Baseline demographics included age (52 ± 13), gender (79% male), size (BSA 1.98), and etiology (37% idiopathic dilated cardiomyopathy; 43% Ischemic). Seventy percent of patients were either INTERMACS 1 or 2. The primary endpoint—defined as successful transplantation or listing at 180 days (prespecified at 65%; 95% lower CI: 57%)—was successfully achieved for the total cohort (67.3%; 95% CI: 59.5%–74.3%; p = 0.006). In subgroup analysis of the more contemporary, cone-bearing group, the primary endpoint was met in 91% (95% CI: 72%–97.5%; p = 0.001). Compared with pin patients, cone-bearing patients had less hemolysis as well as decreased end-organ dysfunction. Functional and quality of life scores improved after implantation independent type of bearing. In conclusion, despite a particularly sick patient population, the Jarvik 2000 was shown to be effective in supporting the advanced HF patient.

Background: Among patients (pts) with coronary artery disease (CAD) who are candidates for coronary artery bypass graft surgery (CABG), a reduced ejection fraction (EF) identifies a high-risk group. The profile of pre-operative, intra-operative and post-operative factors contributing to 30 day (d) mortality in pts with low EF undergoing CABG has not been well characterized. Methods: The STICH trial enrolled 2136 pts with CAD amenable to CABG with an LVEF < 35% who were treated with medical therapy (MED) alone, MED with CABG, or with MED plus CABG and surgical ventricular resconstruction (SVR). Multivariable logistic regression models utilizing extensive baseline, intra-operative and post-operative care variables were developed to determine factors associated with mortality at 30d in a landmark analysis among pts surviving the first 36 hours (h). Results: Among those enrolled, 1460 pts received CABG; 673 (46.1%) on pump, 160 (11.0%) off pump, 132 (9.0%) with a mitral valve procedure (MVR), 393 (26.9%) with SVR, and 102 (7.0%) received CABG with SVR and MVR. Mortality in the operating room (OR) was 0.3 %, within the first 36h was 1.0%, and at 30d was 5.1%. The rate of in-hospital acute myocardial infarction was 0.8%, stroke 1.6%, mediastinitis 1.7%, worsening renal insufficiency 8.4%, and return to OR was 6.9%. Inotropes were used in 43.6% and intra-aortic balloon pump in 18.6%. At 36h, 148 pts (10.2%) remained intubated. Among pts who survived to 36h, a robust multivariable model (Table, c-statistic 0.89) was developed to predict 30d mortality. A prolonged intubation time (>36h) was the strongest marker of 30d mortality (odds ratio 7.4, 95% CI 3.8, 14.5, p<0.0001). Conclusions: Among pts with ischemic heart failure, CABG can be performed with a low rate of complications and intra-operative mortality. Prolonged intubation time (>36h) after CABG is an integrated clincal marker that may serve to identify those pts with the least likelihood of survival to 30d.