Five-year experience with an ECMO programme at a regional heart centre without cardiac surgery on site

Introduction: Extracorporeal membrane oxygenation (ECMO) is a method of extracorporeal circulation which is increasingly used in patients with cardiogenic shock or refractory cardiac arrest. The care is almost exclusively provided in hospitals with cardiac surgery on site.

Methods: A prospective registry of all patients treated with ECMO from April 2015 to March 2020 regardless of the reason for implantation was performed. We assessed the technical success, duration of treatment, complication rate, and in-hospital mortality.

Results: From April 2015 to March 2020, we performed 38 ECMO implementations (31 veno-arterial and 1 veno-venous as well as 6 V-V ECMO procedures for the ICU). All were carried out in a cath lab under x-ray guidance using bifemoral approach (V-V ECMO with femoro-jugular approach). Patients with refractory cardiac arrest were resuscitated with the LUCAS II device during implementation. Circuit priming was managed by a CCU nurse without the presence of a perfusionist while cannulas were inserted by an invasive cardiologist. We performed 32 connections (78 % men, mean age 60.5 ± 11.5 years). The indications were: protected PCI of the left main coronary artery in one case, cardiogenic shock with cardiac arrest in 16 cases, refractory cardiac arrest in eight cases, cardiogenic shock without cardiac arrest in four cases, intoxication in one case, and refractory lung failure in two cases. The aetiology was pulmonary embolism in five cases, myocardial infarction with ST elevation in 18 cases, dilated cardiomyopathy in one case, percutaneous coronary intervention in a high-risk patient in one case, aortic stenosis in one case, non-STEMI in one case, intoxication in one case, and respiratory failure in two cases. Cannulations had a 100 % success rate without any technical complications, but with one episode of bleeding. Twenty-two percent of patients required distal protection for leg ischaemia. Sixteen percent of patients required an intervention for manifestations of disseminated coagulopathy. Successful weaning was achieved in 19 (59 %) of patients, the average time on ECMO was 5.3 ± 1.9 days. Only two patients were subsequently transferred to the cardiac surgery ward (1× aortic valve replacement and 1× LVAD implantation). We observed a 30-day good neurological outcome (CPC 1 and 2) in 13 (41%) patients. The in-hospital mortality was 59 % (7× refractory cardiac arrest, 2× pulmonary embolism, 2× heart failure, 7× multiple organ failure, 1× bleeding). Refractory cardiac arrest had a 100 % mortality rate, cardiogenic shock 33 % (the mortality rate was the same for both groups, i.e. cardiogenic shock with or without cardiac arrest).

Conclusion: Over the course of five years, we performed 38 ECMO implementations as life-saving procedures without any technical complications. Only two patients required subsequent cardiac surgery care. The 30-day survival rate with a good neurological outcome was 41 %, successful weaning was achieved in 59 %. Our experience indicates the feasibility of the ECMO programme in regional centres without cardiac surgery back-up.

Keywords: ECMO, extracorporeal resuscitation, cardiogenic shock.