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Durable Mechanical Circulatory Support Systems
Quick Takes
- A lack of reliable criteria, including appropriate timing and patient selection, for durable mechanical circulatory support (MCS) after extracorporeal life support (ECLS) implantation currently exists.
- In this large European multicenter, retrospective study, factors predicting 1-year outcome in patients needing durable MCS after ECLS included: age, female sex, lactate value, MELD XI score, history of atrial fibrillation, history of previous cardiac surgery, and BMI >30 kg/m2.
- The authors have developed an app called “Durable MCS after ECLS” but the model has not yet been externally validated.
Study Questions:
What are the outcome predictors in patients needing durable mechanical circulatory systems (MCSs) after extracorporeal life support (ECLS) implantation?
Methods:
The Durable MCS after ECLS registry is a multicenter, retrospective study that gathered data on consecutive patients who underwent MCS implantation after ECLS between January 2010 and August 2018, in 11 high-volume European centers. Several perioperative parameters were collected. The primary endpoint was survival at 1 year after durable MCS implantation.
Results:
A total of 531 durable MCS after ECLS were implanted during this study period. The average patient age was 53 ± 12 years old; 82% were male. The mean body mass index (BMI) was 27 ± 6 kg/m2. ECLS cannulation was peripheral in 87% of patients and 33% of the patients had history of cardiopulmonary resuscitation (CPR) before ECLS implantation. The median duration of ECLS before durable MCS implantation was 5 days (interquartile range, 2-8 days). The 30-day, 1-year, and 3-year actuarial survival rates were 77%, 53%, and 43%, respectively. The following predictors for 1-year outcome were observed and used to generate a risk score to estimate 1-year mortality: age, female sex, lactate value, MELD XI score (which excludes the international normalized ratio), history of atrial fibrillation, history of previous cardiac surgery, and BMI >30 kg/m2.
Conclusions:
Outcomes of durable MCS implantation in patients supported by ECLS remain limited, with one in four patients dying during the postoperative period. Several perioperative factors associated with reduced short- and long-term survival were identified and used to generate a risk score to stratify ECLS patients before MCS implantation.
Perspective:
The authors are to be commended for performing the largest multicenter study of durable MCS after ECLS patients. Although the number of ECLS implantations has grown considerably for patients in cardiogenic shock, a concomitant increase in the number of durable MCS implantations after ECLS has not been observed. The authors attempt to address this gap. It is important to recognize that the 30-day and 1-year survival rates (77% and 53%, respectively) are the lowest survival rates reported after any form of contemporary durable MCS therapy. The primary limitation of this study is its retrospective design and thus it is subject to residual confounding. The authors appropriately acknowledge these and other limitations in their discussion. Nonetheless, the study identified several important aforementioned perioperative risk predictors of 1-year mortality in this patient population. This study, of course, merits validation in prospective studies. If the results are shown to be consistent, this Durable MCS after ECLS risk score may facilitate appropriate selection and improve clinical decision making in this vulnerable and challenging patient population.
Clinical Topics: Arrhythmias and Clinical EP, Cardiac Surgery, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Prevention, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias, Cardiac Surgery and Arrhythmias, Cardiac Surgery and Heart Failure, Acute Heart Failure
Keywords: Atrial Fibrillation, Body Mass Index, Cardiac Surgical Procedures, Cardiopulmonary Resuscitation, Catheterization, Critical Illness, Extracorporeal Membrane Oxygenation, Heart Failure, Life Support Care, Risk Assessment, Secondary Prevention, Shock, Cardiogenic, Survival Rate
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