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The condition
Postcardiotomy refers to the period immediately after open-heart surgery. Postcardiotomy cardiogenic shock (PCS) is a rare but life-threatening situation that happens when the efficiency of the heart as a pump is impaired and is unable to meet the body's tissue demands. This means a person may be unable to be separated from cardiopulmonary bypass after open-heart surgery. Persistent cardiogenic shock cannot be managed with pharmacological treatments alone.
Treatment for PCS involves pharmacological treatments, including diuretics and inotropic agents, and mechanical circulatory support, including intra-aortic balloon pumps. Without using mechanical circulatory support PCS has a very high risk of death, with mortality reported as high as 76%.
VA ECMO is used to provide cardiac and respiratory support for people with cardiogenic shock after cardiac surgery. Unlike a heart–lung (cardiopulmonary) bypass machine, it tends to be used for days to weeks and not hours during surgery, allowing the heart time to recover. ECMO provides circulatory support and allows time for other treatments to promote recovery, or may be a bridge to a long-term mechanical solution or transplant. It aims to improve patient outcomes.
NICE did a rapid review of the published literature on the efficacy and safety of this procedure. This comprised a comprehensive literature search and detailed review of the evidence from 10 sources, which was discussed by the committee. The evidence included 4 systematic reviews, 2 retrospective registry studies, 1 multicentre retrospective study and 3 single centre retrospective studies. It is presented in the summary of key evidence section in the interventional procedures overview. Other relevant literature is in the appendix of the overview.
The professional experts and the committee considered the key efficacy outcomes to be: restoration of organ function and bridging to recovery, transplant or long-term support.
The professional experts and the committee considered the key safety outcomes to be: bleeding, leg ischaemia, stroke, infection, renal failure and circuit-related complications.
Patient commentary was sought but none was received.
Clinical experts advised that some centres are providing elective VA ECMO for people who are more likely to have cardiogenic shock after cardiac surgery.
Clinical experts advised that VA ECMO can be done either peripherally or centrally. After cardiac surgery it is common to use central VA ECMO.
The committee noted that it would be difficult to do randomised controlled trials in people with PCS, and that other study designs could be useful.
The committee noted that the recommendations in this guidance include the use of ECMO during pregnancy or in the post-partum period.
Not all cardiac surgery centres specialise in using VA ECMO in the UK. So, people in some areas may not have access to this intervention.
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