2020 EACTS/ELSO/STS/AATS Expert Consensus on Post-Cardiotomy Extracorporeal Life Support in Adult Patients

Post-cardiotomy extracorporeal life support (PC-ECLS) in adult patients has been used only rarely but recent data have shown a remarkable increase its use, almost certainly due to improved technology, ease of management, growing familiarity with capability and decreased costs. Trends worldwide in-hospital survival, however, rather than improving, decline some experiences, likely increased use more complex, critically ill suboptimal management. Nevertheless, PC-ECLS is proving be valuable resource for temporary cardiocirculatory respiratory who would otherwise most die. Because comprehensive review might the practitioner, possibly improve patient management this setting, authors attempted create concise, relevant analysis all aspects related PC-ECLS, particular emphasis on indications, technique, avoidance complications, appraisal new approaches ethics, education training. Dr Lorusso discloses financial relationship LivaNova, Medtronic, Eurosets, PulseCath. All honoraria go university as research funds.The Supplemental Tables Figure can viewed online version article [https://doi.org/10.1016/j.athoracsur.2020.07.009] https://www.annalsthoracicsurgery.org/. funds. The This document represents joint effort by European Association Cardio-Thoracic Surgery (EACTS), Extracorporeal Life Support Organization (ELSO), Society Thoracic Surgeons (STS) American (AATS) provide position paper post-cardiotomy patients, goal which useful recommendations about issues surrounding application highlight several that deserve attention order optimize indications applications, suggest configurations, avoid or manage complications outcomes population are an extremely high risk mortality. Members 4 societies significant experience field were selected invited join task force their respective societies, officially endorsed scientific educational initiative. Following methodological quality assessment across available body evidence specific developed after careful consideration medical knowledge contained each at time writing, following methods manual EACTS clinical guidelines.1Sousa-Uva M. Head S.J. Thielmann Cardillo G. Benedetto U. Czerny et al.Methodology (EACTS) guidelines.Eur J Cardiothorac Surg. 2015; 48: 809-816PubMed Google Scholar After scope guidelines was agreed upon members, table contents established, topics allocated writing groups least 2 members during face-to-face meeting. standardized Population, Intervention, Comparison, Outcome Time (PICOT) framework facilitate systematic literature review, establishing answerable questions. search not restricted terms years mainly focused cardiac surgery adults did include studies languages other English. performed section also instrumental identifying recently published review2Lorusso R. Raffa G.M. Alenizy K. Sluijpers N. Makhoul Brodie D. al.Structured membrane oxygenation: part 1—adult patients.J Heart Lung Transpl. 2019; 38: 1125-1143Abstract Full Text PDF PubMed received further from recognized experts ECLS community. An additional overall complementary PhD fellow dedicated topic (G.R.) member force. appraised epidemiologist (M.M.). chapters written through close collaboration between members. official policy guidelines,1Sousa-Uva asked complete declarations interest write if they had no disclosures topic. Agreement finalized reached conference calls meetings, without excluding conflict interest. hierarchy required study design along internal based formulate levels grades recommendations. In absence evidence, expert consensus statements made cover essential daily practice. level strength weighed graded according predefined scales, outlined 1 2.Table 1Levels EvidenceLevel AData derived multiple randomized trials metaanalyses.Level BData single trial large non-randomized studies.Level CThe opinion and/or small studies, retrospective registries. Open tab Table 2Classes RecommendationsClasses RecommendationsDefinitionSuggested Wording UseClass IEvidence general agreement given treatment procedure beneficial, effective.Is recommended/is indicatedClass IIConflicting divergence usefulness/efficacy procedure. Class IIaWeight evidence/opinion favor usefulness/efficacy.Should considered IIbUsefulness/efficacy less well established evidence/opinion.May consideredClass IIIEvidence/general treatment/procedure useful/effective may sometimes harmful.Is recommended well-established tool rescue refractory failure, concomitant dysfunction, various circumstances lead death. Although since early 1970s, witnessed resurgence setting last decades, particularly surgery.3Stretch Sauer C.M. Yuh D.D. Bonde P. National trends utilization short-term mechanical circulatory support: incidence, outcomes, cost analysis.J Am Coll Cardiol. 2014; 64: 1407-1415Crossref Scopus (238) Scholar,4Maxwell B.G. Powers A.J. Sheikh A.Y. Lee P.H. Lobato R.L. Wong J.K. Resource oxygenation adults: Nationwide Inpatient Sample 1998-2009.J Thorac Cardiovasc 148: 416-421.e1Abstract Technological advances, expertise, availability, affordable costs [a fraction implantable (MCS)] responsible broader use. paralleled continued disappointing characterized morbidity mortality.5Whitman G.J. postcardiotomy shock.J 2017; 153: 95-101Abstract aggressive, resource-intensive clinically demanding procedure, multidisciplinary approach sophisticated expertise paramount importance need exist universally we current results.6Cheng Hachamovitch Kittleson Patel J. Arabia F. Moriguchi al.Complications cardiogenic shock arrest: meta-analysis 1,866 patients.Ann 97: 610-616Abstract (330) Furthermore, although unexpected unforeseen intraoperative postoperative adverse events, many situations it predictable event, allowing timely, post-bypass thereby avoiding irreversible injury cardiac, cardiorespiratory failure. Patient selection, timely application, presence educated well-trained users, adequate precautions implantation principles, periprocedural weaning protocol recognition futility cessation therapy even advanced therapies, represent components theoretically could success high-risk patients. identify important vade mecum decision-making (Supplemental 1-3). refers ECLS-related terminology included (modified Broman colleagues.7Broman L.M. Taccone F.S. Malfertheiner M.V. Pappalardo Di Nardo al.The Maastricht treaty nomenclature: abbreviations cannulation configuration support. A Organization.Crit Care. 23: 36Crossref (0) released ELSO (Table 3). accounts addresses oxygenator, known (ECMO). Other described (ST-MCS) long-term (LT-MCS).8Potapov E.V. Crespo-Leiro M.G. Combes A. Farber Hannan M.M. Kukucka al.Expert support.Eur 56: 230-270Crossref ScholarTable 3Nomenclature Modes ConfigurationsECLS?A collective term therapies presentations pulmonary failure ECC?ECLS includes focusing oxygenation, CO2 removal, combination thereof. It excludes ECC cardiothoracic vascular surgical proceduresECMO?ECMO provision O2 exchange circuit consisting minimally blood pump, artificial lung access cannula, using flows sufficient concomitantly enhance removal?The interchangeably ECMO, ECMO commonly when delivery means pumped circuitVA support?V-A primarily cardiopulmonary support, drains venous system returns systemic arterial oxygenated normalized pCO2. Without qualification, V-A system, operating parallel providing partial bypass heart lungs. circumstances, combined qualify (V-A ECLS)VV support?V-V reinfuses into system. V-V operates series lungs does these organs?V-V (V-V ECLS). Variations a) dual-lumen cannula inserted tricuspid valve artery supports RV function addition gas (also called Oxy-RVAD) b) configurations (a right atriopulmonary right-to-left atrium connection pump oxygenators isolated dysfunction occurs)V-VA support?V-VA hybrid both systems. V-VA provides component) failure?Other possible (called ECLS) provided ELSO.7Broman Scholar?V-VA (V-VA abbreviation preferred over V-AV contraction ‘V-V’ ‘V-A’ literatureECPR?ECPR rapid-deployment ECLS, usually peripheral cannulation, whom conventional CPR unsuccessful achieving sustained ROSC. Sustained ROSC deemed occurred chest compressions 20 consecutive min signs circulation persist?ECPR implies CPR. Use initiated LCO ECPRProlonged ECLS?A continuous episode 7–10 days 28 ECLS. indicate type mode ECLSCO2, carbon dioxide; CPR, resuscitation; ECC, circulation; support; oxygenation; ECPR, ELSO, Organization; LCO, low output; LV, left ventricular; O2, oxygen; Oxy-RVAD, ventricular assist device oxygenator; ROSC, return spontaneous RV, V-AV, veno-arterialvenous; V-VA, veno-venousarterial; VA, veno-arterial; VV, veno-venous. CO2, increasing dramatically acute compromises, e.g. arrest, embolism, severe myocardial infarction (MI), categories unresponsive aggressive treatments.3Stretch rapidly becoming supporting experiencing compromise intraoperatively, preoperatively postoperatively.4Maxwell Scholar,5Whitman As previously mentioned, factors promoted PC-ECLS,3Stretch devices proposed setting.9Keebler M.E. Haddad Choi C.W. McGrane S. Zalawadiya Schlendorf K.H. al.Venoarterial shock.JACC Fail. 2018; 6: 503-516Crossref (47) Scholar,10Pitsis A.A. Visouli A.N. Burkhoff Dardas Mezilis Bougioukas al.Feasibility percutaneous surgery.Ann 2007; 84: 1993-1999Abstract (24) attempts reader help practitioner fully understand strengths limitations those human prerequisite successful outcomes. Alternative caring briefly touched upon. Information perioperative limited. Indeed, few robust (>50 cases) reported 25 years.11Chamogeorgakis T. Rafael Shafii A.E. Nagpal Pokersnik J.A. Gonzalez-Stawinski G.V. Which better: miniaturized shock?.ASAIO 2013; 59: 607-611Crossref (33) Scholar,12Raffa Gelsomino Meani Natour E. al.In-hospital outcome patients: 2007-2017 experience.Crit Care Resusc. 19: 53-61PubMed Prevalence ranges 0.3% 3.6%,2Lorusso Scholar,11Chamogeorgakis highlighting limited highly variable setting. national international surveys confirmed subjects,3Stretch Registry reveals steady number survivors.5Whitman decreasing percentage cases, decrease result non-surgical arrest. However, because absolute cases increasing, continues common patients.13McCarthy F.H. McDermott K.M. Kini V. Gutsche J.T. Wald J.W. Xie al.Trends U.S. outcomes: 2002-2012.Semin 27: 81-88Abstract characteristics potentially associated investigated, clearly defined profiles identified. Relatively young age (<60 years), preoperative renal insufficiency, prior MI, left-main disease, (LV) prolonged history coronary disease previous open-heart urgent emergent status, characterize patient.14Fux Holm Corbascio Lund L.H. van der Linden Venoarterial shock: mortality.J 156: 1894-1902Abstract (21) controversial aspect PC-ECLS. Several centers deny above cut-off age, whereas majority regard older relative contraindication.15Lorusso Cariou Flaatten H. dilemma resuscitation.Intensive Med. 45: 542-544Crossref Scholar,16Saxena Neal Joyce L.D. Greason K.L. Schaff H.V. Guru al.Extracorporeal elderly mayo clinic experience.Ann 99: 2053-2060Abstract (40) expected, procedural volumes, frequent subgroup represented grafting (CABG), followed surgery, valve/coronary others.2Lorusso noteworthy despite being contraindication, post-repair aortic dissection longer contraindication. effective assistance transplantation (HTx) (LVAD) implantation.2Lorusso 10–15% HTx LVAD, representing invaluable such settings.17Lima E.B. Cunha C.R. Barzilai V.S. Ulhoa M.B. Barros M.R. Moraes C.S. al.Experience primary graft orthotopic transplantation.Arq Bras 105: 285-291PubMed Scholar,18Kittleson J.D. Kawano Davis Hage al.Heart transplant recipients supported single-center experience.J Transplant. 2011; 30: 1250-1256Abstract (44) marginal donor hearts, predisposing pool size. apparently influence recovery survival discharge.19Listijono D.R. Watson Pye Keogh A.M. Kotlyar Spratt al.Usefulness allograft dysfunction.J 783-789Abstract (49) LVAD implantation, (RV) occurs 25% often requiring regardless type.20Dandel Krabatsch Falk Left vs. biventricular strategies implantation.Int 198: 241-250Abstract Scholar,21Haneya Philipp Puehler Rupprecht L. Kobuch Hilker al.Temporary centrifugal implantation.Eur 2012; 41: 219-223Crossref (6) increasingly while recovers bridge decision regarding (RVAD).21Haneya Scholar,22Argiriou Kolokotron S.M. Sakellaridis Argiriou O. Charitos C. Zarogoulidis al.Right post implantation.J Dis. S52-S59PubMed PC arrest frequently 10 years, constant time23Zhao Y. Xing Du Z. Liu Jia Hou X. resuscitation underwent post-cardiac surgery.Eur Med Res. 20: 83Crossref promising results reflected latest 2017 STS Expert Consensus Resuscitation Patients Who Arrest Cardiac Surgery.24Society Task Force SurgeryThe 103: 1005-1020Abstract (29) caregivers face comorbidities conditions distinguish candidate (Figure 1). remains infrequent complication <4% undergoing surgery.2Lorusso