title: Percutaneous extracorporeal life support for patients in therapy refractory cardiogenic shock: initial results of an interdisciplinary team.
abstract: OBJECTIVE
  Therapy refractory cardiogenic shock is associated with dismal outcome. Percutaneous implantation of an extracorporeal life support (ECLS) system achieves immediate cardiopulmonary stabilization, sufficient end-organ perfusion and reduction of subsequent multiorgan failure (MOF).
  
  
  METHODS
  Forty-one patients undergoing percutaneous ECLS implantation for cardiogenic shock from February 2012 until August 2013 were retrospectively analysed. Mean age was 52 ± 13 years, 6 (15%) were female. Mean pH values obtained before ECLS implantation were 7.15 ± 0.24, mean lactate concentration was 11.7 ± 6.4 mmol/l. Levels obtained 6 h after ECLS implantation were 7.30 ± 0.14 and 8.7 ± 5.0 mmol/l, respectively. In 23 patients (56%) cardiogenic shock resulted from an acute coronary syndrome in 13 (32%) from cardiomyopathy, in 5 (12%) from other causes. Twenty-seven (66%) had been resuscitated, in 14 (34%) implantation was performed under ongoing cardiopulmonary resuscitation (CPR). Of note, 97% of the acute coronary syndrome patients underwent percutaneous coronary intervention (PCI) either before ECLS implantation or under ECLS support. Extracorporeal life support implantation was performed on scene (Emergency Department, Cath Lab, Intensive Care Unit) by a senior cardiac surgeon and a trained perfusionist, in 8 cases (20%) in the referring hospital.
  
  
  RESULTS
  Thirty-day mortality was 51% [21 patients, due to MOF (n = 14), cerebral complications (n = 6) and heart failure (n = 1)]. Logistic regression analysis identified 6-h pH values as an independent risk factor of 30-day mortality (P < 0.001, OR = 0.000, 95% CI 0.000-0.042). Neither CPR nor implantation under ongoing CPR resulted in significant differences. In 26 cases (63%), the ECLS system could be explanted, after mean support of 169 ± 67 h. Seven of these patients received cardiac surgery [ventricular assist device implantation (n = 4), heart transplantation (n = 1), other procedures (n = 2)].
  
  
  CONCLUSIONS
  Due to the evolution of transportable ECLS systems and percutaneous techniques implantation on scene is feasible. Extracorporeal life support may serve as a bridge-to-decision and bridge-to-treatment device. Neurological evaluation before ventricular assist device implantation and PCI under stable conditions are possible. Despite substantial mortality, ECLS implantation in selected patients by an experienced team offers additional support to conventional therapy as well as CPR and allows survival in patients that otherwise most likely would have died. This concept has to be implemented in cardiac survival networks in the future.
authors: Department of Cardiac Surgery, University Hospital Munich, Ludwig-Maximilian-University, Munich, Germany.
authors: Sabina
authors: S
authors: Guenther
authors: Hans D
authors: HD
authors: Theiss
authors: Matthias
authors: M
authors: Fischer
authors: Stefan
authors: S
authors: Sattler
authors: Sven
authors: S
authors: Peterss
authors: Frank
authors: F
authors: Born
authors: Maximilian
authors: M
authors: Pichlmaier
authors: Steffen
authors: S
authors: Massberg
authors: Christian
authors: C
authors: Hagl
authors: Nawid
authors: N
authors: Khaladj
mesh_terms: D054058:Acute Coronary Syndrome / Q000150:complications; D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D015415:Biomarkers / Q000097:blood; D009202:Cardiomyopathies / Q000150:complications; D004867:Equipment Design; D015199:Extracorporeal Membrane Oxygenation / Q000009:adverse effects / Q000295:instrumentation / Q000401:mortality; D005260:Female; D006439:Hemodynamics; D006801:Humans; D006863:Hydrogen-Ion Concentration; D019344:Lactic Acid / Q000097:blood; D008297:Male; D008875:Middle Aged; D010107:Oxygenators, Membrane; D010348:Patient Care Team; D012189:Retrospective Studies; D012307:Risk Factors; D012770:Shock, Cardiogenic / Q000097:blood / Q000175:diagnosis / Q000209:etiology / Q000401:mortality / Q000503:physiopathology / Q000628:therapy*; D013997:Time Factors; D016896:Treatment Outcome; D055815:Young Adult
chemical_list: D015415:Biomarkers; D019344:Lactic Acid
keywords: Cardiogenic shock; Cardiomyopathy; Extracorporeal life support; Myocardial infarction