title: When all else fails: extracorporeal life support in therapy-refractory cardiogenic shock.
abstract: OBJECTIVE
  No guidelines for mechanical circulatory support in patients with therapy-refractory cardiogenic shock and multiorgan failure including ongoing cardiopulmonary resuscitation (CPR) exist. To achieve immediate cardiopulmonary stabilization, we established an interdisciplinary concept with on-site percutaneous extracorporeal life support (ECLS) implantation.
  
  
  METHODS
  From February 2012 to November 2014, 96 patients were deemed eligible for ECLS implantation. Establishing ECLS was successful in 87 patients (mean age 54 ± 13 years, 16% female, initial flow 4.4 ± 0.9 l/min). Aetiologies included acute coronary syndromes (n = 52, 60%), cardiomyopathies (n = 25, 29%) and other pathologies. Fifty-nine patients (68%) had been resuscitated, and in 27 (31%), implantation was performed during CPR; 11 patients (13%) were awake at implantation and 20 (23%) underwent implantation in the referring hospital.
  
  
  RESULTS
  Metabolic parameters differed in non-survivors versus survivors before ECLS implantation (pH 7.15 ± 0.23 vs. 7.27 ± 0.18, P = 0.007; lactate levels 10.90 ± 6.00 mmol/l vs. 8.79 ± 5.78 mmol/l, P = 0.091) and 6 h postimplantation (pH 7.27 ± 0.11 vs. 7.37 ± 0.11, P < 0.001; lactate levels 10.19 ± 5.52 mmol/l vs. 5.52 ± 4.17 mmol/l, P < 0.001). Altogether 44 patients could be weaned, and 9 were bridged to assist device implantation and 1 to heart transplantation. The mean time of support was 6 days, and the 30-day survival rate was 47% (n = 41).
  
  
  CONCLUSIONS
  ECLS serves as a bridge-to-decision and bridge-to-treatment device. Our interdisciplinary ECLS programme achieved acceptable survival of critically ill patients despite a substantial percentage of patients having been resuscitated and no absolute exclusion criteria. Further studies defining inclusion- and exclusion criteria might additionally improve outcome.
authors.affiliation: Department of Cardiac Surgery, University Hospital Munich, Ludwig-Maximilian-University, Munich, Germany sabina.guenther@med.uni-muenchen.de.
authors.forename: Sabina P W
authors.initials: SP
authors.lastname: Guenther
authors.affiliation: Medical Department I (Cardiology), University Hospital Munich, Ludwig-Maximilian-University, Munich, Germany.
authors.forename: Stefan
authors.initials: S
authors.lastname: Brunner
authors.affiliation: Department of Cardiac Surgery, University Hospital Munich, Ludwig-Maximilian-University, Munich, Germany.
authors.forename: Frank
authors.initials: F
authors.lastname: Born
authors.affiliation: Department of Cardiac Surgery, University Hospital Munich, Ludwig-Maximilian-University, Munich, Germany.
authors.forename: Matthias
authors.initials: M
authors.lastname: Fischer
authors.affiliation: Department of Cardiac Surgery, University Hospital Munich, Ludwig-Maximilian-University, Munich, Germany.
authors.forename: René
authors.initials: R
authors.lastname: Schramm
authors.affiliation: Department of Cardiac Surgery, University Hospital Munich, Ludwig-Maximilian-University, Munich, Germany.
authors.forename: Maximilian
authors.initials: M
authors.lastname: Pichlmaier
authors.affiliation: Medical Department I (Cardiology), University Hospital Munich, Ludwig-Maximilian-University, Munich, Germany.
authors.forename: Steffen
authors.initials: S
authors.lastname: Massberg
authors.affiliation: Department of Cardiac Surgery, University Hospital Munich, Ludwig-Maximilian-University, Munich, Germany.
authors.forename: Christian
authors.initials: C
authors.lastname: Hagl
authors.affiliation: Department of Cardiac Surgery, University Hospital Munich, Ludwig-Maximilian-University, Munich, Germany.
authors.forename: Nawid
authors.initials: N
authors.lastname: Khaladj
mesh_terms: D000368:Aged; D016887:Cardiopulmonary Resuscitation; D005112:Extracorporeal Circulation / Q000401:mortality*; D005260:Female; D006331:Heart Diseases / Q000150:complications; D006801:Humans; D053208:Kaplan-Meier Estimate; D008297:Male; D008875:Middle Aged; D012189:Retrospective Studies; D012770:Shock, Cardiogenic / Q000209:etiology / Q000601:surgery*; D016896:Treatment Outcome
keywords: Cardiogenic shock; Cardiomyopathy; Cardiopulmonary resuscitation; Extracorporeal life support; Myocardial infarction