Interventional procedure overview of VA ECMO for postcardiotomy cardiogenic shock in adults

Baldan BU, Hegeman, RR, Bos NM et al. (2024) Comparative analysis of therapeutic strategies in post-cardiotomy cardiogenic shock: insight into a high-volume cardiac surgery center. Journal of Clinical Medicine 13: 2118

In people who had ECMO (n=73), the in-hospital mortality was 60%, compared to an in-hospital mortality of 85% for those who had conservative management (n=52). In 18 (25%) people who had ECMO, the plasma lactate level normalised within 48 hours, compared to 2 (4%) in the non-ECMO group. The morbidity in the non-ECMO group compared to ECMO included a need for dialysis (42% versus 60%), myocardial infarction (19% versus 27%), and cerebrovascular accident (17% versus 12%).

Larger studies are included.

Baran C, Ozcinar E, Kayan A et al. (2024) Comparison of ECMO, IABP and ECMO + IABP in the postoperative period in patients with postcardiotomy shock.

Journal of Cardiovascular Development and Disease 11: 283

The weaning rate from VA ECMO was significantly higher in the combined VA ECMO and IABP group (81%) compared with the other groups (p=0.004). One-year survival was also higher in the combined group (76%) (p=0.002). Complications or renal function did not differ significantly among the groups.

Studies with more people or longer follow-up are included.

Biancari F, Makikallio T, L'Acqua C et al. (2025) How long should patients be treated with postcardiotomy venoarterial extracorporeal membrane oxygenation? Individual Patient Data Pooled Analysis. Critical Care Medicine 53: e908

In-hospital mortality was lowest among those treated 3 to 6 days with VA ECMO. Multilevel mixed-effects logistic regression considering the cluster effect of the participating hospitals adjusted for individual patient's risk profile and operative variables showed that the risk in-hospital mortality did not significantly increase in people treated more than 6 days up to 20 days.

Review focuses on duration of treatment.

Biancari F, Kaserer A, Perrotti A et al. (2024) Hyperlactatemia and poor outcome After postcardiotomy veno-arterial extracorporeal membrane oxygenation: An individual patient data meta-Analysis. Perfusion 39: 956-965

Arterial lactate level at VA ECMO initiation was increased in those who died during the index hospitalisation compared to those who survived (9.3 versus 6.6 mmol/litre, p<0.0001). Accordingly, in-hospital mortality increased along quintiles of pre-VA ECMO arterial lactate level (quintiles: 1, 55%; 2, 55%; 3, 67%; 4, 74%; 5, 82%, p<0.0001). The best cut-off for arterial lactate was 6.8 mmol/litre (in-hospital mortality, 77% versus 56%, p<0.0001).

Review focuses on prognostic impact of arterial lactate level before starting VA ECMO.

Biancari F, Makikallio T, Loforte A et al. (2024) Inter-institutional analysis of the outcome after postcardiotomy veno-arterial extracorporeal membrane oxygenation.

The International Journal of Artificial Organs 47: 25-34

In-hospital mortality was 67%. Observed versus expected in-hospital mortality ratio showed that 4 hospitals were outliers with significantly increased mortality rates, and 1 hospital had significantly lower in-hospital mortality rate.

Review focuses on comparison of outcomes from different institutions.

Biancari F, Kaserer A, Perrotti A et al. (2022) Central versus peripheral postcardiotomy veno-arterial extracorporeal membrane oxygenation: systematic review and individual patient data meta-analysis. Journal of Clinical Medicine 11: 7406

Crude rates of in-hospital mortality after central versus peripheral arterial cannulation for VA ECMO were 71% versus 64%, respectively (adjusted OR 1.38, 95% CI 1.08 to 1.75). Among propensity score matched cohorts, central arterial cannulation VA ECMO was associated with statistically significantly higher in-hospital mortality compared to peripheral arterial cannulation VA ECMO (64% versus 71%, p=0.027).

Review focuses on central versus peripheral cannulation.

Biancari F, Dalen M, Fiore A et al. (2022) Gender and the outcome of postcardiotomy veno-arterial extracorporeal membrane oxygenation. Journal of Cardiothoracic and Vascular Anesthesia 36: 1678–85

Among 94 propensity score-matched pairs, women had a higher hospital mortality (70% versus 56%, p=0.049) compared with men. Logistic regression analysis showed that women (OR 1.87; 95% CI 1.10 to 3.16), age (OR 1.06; 95% CI 1.04 to 1.08) and pre-ECMO arterial lactate (OR 1.09; 95% CI 1.04 to 1.16) were independent predictors of hospital mortality. Among propensity score-matched pairs, 1-, 3-, and 5-year mortality were 61%, 65%, and 65% among men, and 71%, 71%, and 74% among women, respectively (p=0.110, adjusted HR 1.27; 95% CI 0.96 to 1.66).

Small study focusing on the effect of gender on outcomes.

Biancari F, Saeed D, Fiore A et al. (2019) Postcardiotomy venoarterial extracorporeal membrane oxygenation in patients aged 70 years or older.

The Annals of Thoracic Surgery 108: 1257-1264

Hospital mortality in the overall series was 64%. In the 255 people who were 70 years or older (33%), hospital mortality was statistically significantly higher than in younger patients (76% versus 59%; adjusted OR 2.20; 95% CI 1.54 to 3.15). Arterial lactate level greater than 6 mmol/litre before starting VA ECMO was the only predictor of hospital mortality among older people in univariate analysis (83% versus 70%; p=0.029). Meta-analysis of current and previous studies showed that early mortality after postcardiotomy VA ECMO was statistically significantly higher in people aged 70 years or older compared with younger people (OR 2.09; 95% CI 1.59 to 2.75; 5 studies including 1,547 people; I²=6%). The pooled early mortality rate among people aged 70 years or older was 79% (95% CI 74.1 to 83.5; 6 studies including 617 people; I²=42%). Two studies reported 1-year mortality (including hospital mortality) of 80% and 76%, respectively, in people aged 70 years or older.

Studies with more people or longer follow-up are included.

Biancari F, Fiore A, Jonsson K et al. (2019) Prognostic significance of arterial lactate levels at weaning from postcardiotomy venoarterial extracorporeal membrane oxygenation.

Journal of Clinical Medicine 8: 2218

Arterial lactate levels at weaning from VA ECMO (adjusted OR 1.43, 95% CI 1.16 to 1.76) was an independent predictor of hospital mortality, and its best cutoff values was 1.6 mmol/litre (less than 1.6 mmol/litre=26% versus 45% for 1.6 mmol/litre or above; adjusted OR 2.49, 95% CI 1.37 to 4.50). Among 87 propensity score-matched pairs, hospital mortality was statistically significantly higher in those with arterial lactate 1.4 mmol/litre or above (39% versus 23%, p=0.029) compared to those with lower arterial lactate.

The main results from the study are published in Biancari (2020).

Bunge JJH, Mariani S, Meuwese C et al. (2024) characteristics and outcomes of prolonged venoarterial extracorporeal membrane oxygenation after cardiac surgery: the post-cardiotomy extracorporeal life support (pels-1) cohort study.

Critical Care Medicine 52: e490–502

Duration of post cardiotomy ECMO was 0 to 3 days in 649 people (32%), 4 to 7 days in 776 (38%), 8 to 10 days in 263 (13%), and more than 10 days in 333 (16%) people. In-hospital mortality increased after 7 days of support, especially in people having valvular and complex surgery, or who had complications, although the long-term post-discharge prognosis was comparable to PC ECMO with shorter support duration.

Study focuses on duration of ECMO.

There were other indications for post-cardiotomy VA ECMO as well as cardiogenic shock.

Carroll BJ, Shah RV, Murthy V et al. (2015) Clinical features and outcomes in adults with cardiogenic shock supported by extracorporeal membrane oxygenation. The American Journal of Cardiology 116(10): 1624-30

Overall, 69 people (56%) were weaned from ECMO, with 48 patients (39%) surviving to discharge. People with postcardiotomy shock had the poorest overall survival after ECMO.

Included in Kowalewski (2020) SLR.

Chiarini G, Mariani S, Schaefer A-K et al. (2024) Neurologic complications in patients receiving aortic versus subclavian versus femoral arterial cannulation for post-cardiotomy extracorporeal life support: results of the PELS observational multicenter study. Critical Care 28: 265

Subclavian or axillary cannulation was associated with higher rates of major neurological complications and seizures. In-hospital mortality was higher after aortic cannulation, despite no statistically significant differences in incidence of neurological cause of death in these people.

Study focuses on the association between cannulation site and neurological complications.

Distelmaier K, Wiedemann D, Binder C et al. (2018) Duration of extracorporeal membrane oxygenation support and survival in cardiovascular surgery patients. Journal of Thoracic and Cardiovascular Surgery 155(6): 2471-2476

Through a median follow-up period of 45 months, 245 people (69%) died. An association between increased duration of ECMO support and mortality was observed in people who survived ECMO support with a crude hazard ratio of 1.96 (95% CI 1.40 to 2.74; p<0.001) for 2 year mortality compared with the third tertile and the second tertile of ECMO duration.

Included in Kowalewski (2020) SLR.

Djordjevic I, Eghbalzadeh K, Sabashnikov A et al. (2020) Central vs peripheral venoarterial ECMO in postcardiotomy cardiogenic shock. Journal of Cardiac Surgery 35(5): 1037-1042

30‐day mortality was comparable with nearly 70% in both cohorts (cECMO 39 [70%] vs pECMO 69 [69%]; p=0.93). ECMO complications occurred significantly more frequently in people treated with cECMO (cECMO 44 [79%] vs pECMO 54 [54%]; p<0.01).

Outcomes not reported as overall population, but by subgroup: central or peripheral VA ECMO.

Flecher E, Anselmi A, Corbineau H et al. (2014) Current aspects of extracorporeal membrane oxygenation in a tertiary referral centre: determinants of survival at follow-up. European journal of cardio-thoracic surgery : official journal of the European Association for Cardio-thoracic Surgery 46(4): 665-671

Overall in the VA group, weaning rates were 59%, survival after 30 days was 44% and survival at the end of the follow-up was 41%.

More recent studies with outcomes split by aetiologies were included.

Fux T, Holm M, Corbascio M et al. (2018) Venoarterial extracorporeal membrane oxygenation for postcardiotomy shock: Risk factors for mortality. The Journal of Thoracic and Cardiovascular Surgery 156(5): 1894-1902e3

The 90-day overall mortality was 57%, and in-hospital mortality was 56%. Forty-seven percent of patients died on venoarterial extracorporeal membrane oxygenation, 51% of patients were successfully weaned, 1% of patients were bridged to heart transplantation, and 1%of patients were bridged to left ventricular assist device.

Included in Alba (2021) SLR.

Hanuna M, Herz G, Stanzl AL et al. (2024) Mid-Term Outcome after Extracorporeal Life Support in Postcardiotomy Cardiogenic Shock: Recovery and Quality of Life. Journal of Clinical Medicine 13: 2254

Estimated survival rates at 3, 12, 24 and 36 months were 47%, 46%, 43% and 43% (SE: 4%). Multivariable Cox Proportional Hazard regression analysis revealed preoperative EuroSCORE II (p=0.013), impaired renal function (p=0.010), cardiopulmonary bypass duration (p = 0.015) and pre-ECLS lactate levels (p=0.004) as independent predictors of mid-term mortality. At the time of follow-up, 83% of the survivors were free of moderate to severe disability (mRS less than 3). SF-36 analysis showed a physical component summary of 45.5 and a mental component summary of 50.6.

Studies with more people or longer follow-up are included.

Hess NR, Wang Y, Kilic A (2021) Utilization and outcomes of postcardiotomy mechanical circulatory support. Journal of Cardiac Surgery 36: 4030–37

442 (83%) of people were supported with intra-aortic balloon pump counterpulsation, 23 (4%) with an Impella device, and 115 (22%) with ECMO. Three people had an unplanned ventricular assist device placed. Operative mortality was 30%. Longitudinal survival was 56% and 43% at 1 and 5 years, respectively. Survival was lowest in those supported with ECMO and highest with those supported with an Impella (p<0.001). Freedom from readmission was 61% at 5 years. Postoperative ECMO was an independent predictor of mortality (HR 5.1, 95% CI 2.0 to 12.9, p<0.001), but none of the MCS types predicted long-term hospital readmission after risk adjustment.

Only a small proportion of people had ECMO.

Heuts S, Mariani S, van Bussel BCT et al. (2023) The Relation Between Obesity and Mortality in Postcardiotomy Venoarterial Membrane Oxygenation. The Annals of Thoracic Surgery 116: 147–54

In-hospital mortality was 60%, without statistically significant differences among BMI classes for in-hospital mortality (p=0.225) or major adverse events (p=0.126). The crude association between BMI and in-hospital mortality was not statistically significant after adjustment for comorbidities and intraoperative variables (class 1: OR 1.21; 95% CI

0.88 to 1.65; class 2: OR 1.45; 95% CI 0.86 to 2.45; class 3: OR 1.43; 95% CI 0.62 to 3.33), which was confirmed in multiple sensitivity analyses.

Study focuses on the effect of obesity on outcomes.

There were other indications for post-cardiotomy VA ECMO as well as cardiogenic shock.

Hohri Y, Zhao Y, Takayama H et al. (2025) Relationship between indexed surgery and postcardiotomy extracorporeal life support outcomes. Perfusion 40: 915–22

Major cardiac surgery

included aortic surgery (n=35, 24%), CABG alone (n=29, 20%), valve surgery alone (n=59, 40%), and concomitant CABG and valve surgery (n=26, 17%). In-hospital mortality was worst in the CABG and valve surgery group (p<0.01), and the incidence of

acute kidney injury was highest in the aortic surgery group (p=0.03). In multivariable logistic regression, CABG and valve surgery (OR 4.20, 95% CI 1.30 to 13.6, p=0.02) and lactate level at ECLS initiation (OR 1.17; 95% CI 1.06 to 1.29; p<0.01) were independently associated with mortality.

Studies with more people or longer follow-up are included.

Hou D, Wang H, Yang F et al. (2021) Neurologic Complications in Adult Post-cardiotomy Cardiogenic Shock Patients Receiving Venoarterial Extracorporeal Membrane Oxygenation: A Cohort Study. Frontiers in Medicine 8: 721774

Neurological complications happened in 87 people (21%), including cerebral infarction in 33 (8%), brain death in 30 (7%), seizures in 14 (3%), and intracranial haemorrhage in 11 (3%) people. In-hospital mortality in those with neurological complications was 91%, compared to 52% in controls (p<0.001). In a multivariable model, the lowest systolic blood pressure (SBP) level before ECMO (OR 0.89; 95% CI 0.86 to 0.93) and aortic surgery combined with coronary artery bypass grafting (OR 9.22; 95% CI 2.10 to 40.55) were associated with overall neurological complications. Age (OR 1.06; 95% CI 1.01 to 1.12) and lowest SBP (OR 0.81; 95% CI 0.76 to 0.87) were correlative factors of brain death. Coagulation disorders (OR 9.75; 95% CI 1.83 to 51.89) and atrial fibrillation (OR 12.19; 95% CI 1.22 to 121.61) were associated independently with intracranial haemorrhage, whereas atrial fibrillation (OR 8.15; 95% CI 1.31 to 50.62) was also associated with cerebral infarction.

Studies with more people or longer follow-up are included.

Ivanov B, Krasivskyi I, Gerfer S et al. (2022) Impact of Initial Operative Urgency on Short-Term Outcomes in Patients Treated with ECMO Due to Postcardiotomy Cardiogenic Shock.

Life 12 (no. 11)

The direct comparison between patients divided into groups based on urgency showed that in-hospital mortality rates were comparable between the groups.

Studies with more people or longer follow-up are included.

Kakuturu J, Dhamija A, Chan E et al. (2023) Mortality and cost of post-cardiotomy extracorporeal support in the United States. Perfusion 38: 1468–77

2,000 (45%) hospitalisations involved isolated valvular procedures, 1,700 (38%) isolated CABG, and 775 (17%) involved a combination of both. Overall, in-hospital

mortality was 42% (n=1,880). Factors statistically significantly associated with in-hospital mortality included patients with

multiple comorbidities (more than 7) and those having combination of valve and CABG procedures. Only 27% of those who survived to discharge, were discharged home independently.

Studies with more relevant outcomes are included.

Khorsandi M, Dougherty S, Bouamra O et al. (2017) Extra-corporeal membrane oxygenation for refractory cardiogenic shock after adult cardiac surgery: a systematic review and meta-analysis. Journal of cardiothoracic surgery 12(1): 55

Meta-analysis for overall survival rate to hospital discharge of 31% (95% CI 0.29 to 0.34, p<0.01, I²=60%).

More recent systematic reviews and meta-analyses included.

Kienlein RM, Trauzeddel RF et al. (2025) Outcome and complications in postcardiotomy cardiogenic shock treated with extracorporeal life support - a systematic review and meta-analysis. BMC Anesthesiology 25: 29

Successful weaning from extracorporeal life support was accomplished in 53% (31% to 57%) and 31% were discharged alive (mortality of 25 to 56% after weaning). 95% of people had at least 1 complication. Diabetes mellitus and obesity seem to be independent risk factors for poor outcome.

Only 5 studies were included.

Kowalewski M, Raffa G, Zielinski K et al. (2020) Baseline surgical status and short-term mortality after extracorporeal membrane oxygenation for post-cardiotomy shock: a meta-analysis. Perfusion 35(3): 246-254

Overall in-hospital or 30-day mortality event rate was 67% (95% CI 63 to 70%). There were no differences in in-hospital or 30-day mortality with respect to baseline surgical status in the subgroup analysis (test for subgroup differences; p=0.406).

Studies with more relevant outcomes were included.

Laimoud M, Hakami E, Machado P et al. (2024) Appropriate timing of veno-arterial extracorporeal membrane oxygenation initiation after cardiac surgery. Cardiothoracic Surgeon 32: 2

81 (53%) people were intra-operatively supported with VA ECMO while 71 (47%) people were postoperatively supported. Postponed postoperative ECMO insertion was associated with an increased risk of death (HR 1.628, 95% CI 1.102 to 2.403, p=0.014).

Postponed ECMO insertion in critically sick people was associated with increased mortality after cardiac surgery. Early intraoperative initiation of post-cardiotomy ECMO may have the potential to improve outcomes after cardiac surgery.

Small study, focusing on the timing of VA ECMO.

Mariani S, Perazzo A, De Piero ME et al. (2025) Postcardiotomy extracorporeal membrane oxygenation after elective, urgent, and emergency cardiac operations: Insights from the PELS observational study.

JTCVS open 24: 280-310

One-quarter of postcardiotomy VA ECMOs were implemented after emergency operations. Despite more complications in emergency cases, in-hospital and 5-year survival were comparable between emergency, urgent, or elective

operations.

Study describes characteristics and outcomes of people having cardiac operations and requiring VA ECMO, stratified by emergency, urgent, or elective operation. Another paper from the same study is included (Mariani 2023a).

Study focuses on outcomes for females versus males.

Another paper from the same study is included (Mariani 2023a).

Mariani S, van Bussel BCT, Ravaux JM et al. (2023) Variables associated with in-hospital and postdischarge outcomes after postcardiotomy extracorporeal membrane oxygenation: Netherlands Heart Registration Cohort. Journal of Thoracic and Cardiovascular Surgery 165(3): 1127-1137e14

In-hospital mortality was 52%, with death occurring in a median of 5 days (IQR 2 to 14 days) after surgery. Hospital survivors (n=196) experienced considerable rates of pulmonary infections, respiratory failure, arrhythmias, and deep sternal wound infections during a hospitalisation of median 29 days (IQR 17 to 51 days).

Larger registry studies from broader regions included.

Mariani S, Wang I-W, van Bussel BCT et al. (2023c) The importance of timing in postcardiotomy venoarterial extracorporeal membrane oxygenation: A descriptive multicenter observational study.

The Journal of Thoracic and Cardiovascular Surgery 166: 1670-1682e33

Cardiogenic shock (45%), right ventricular failure (16%), and cardiac arrest (14%) were the main indications for postoperative ECMO initiation, with cannulation occurring after (median) 1 day (IQR, 1 to 3 days). Compared with intraoperative application, patients who had postoperative ECMO showed more complications, cardiac reoperations (intraoperative: 20%; postoperative: 25%, p=0.011), percutaneous coronary interventions (intraoperative: 2%; postoperative: 4%, p=0.026), and had greater in-hospital mortality (intraoperative: 58%; postoperative: 64%, p=0.002).

Another paper from the same study is included (Mariani 2023a).

Mariscalco G, El-Dean Z, Yusuff H et al. (2021) Duration of Venoarterial Extracorporeal Membrane Oxygenation and Mortality in Postcardiotomy Cardiogenic Shock.

Journal of Cardiothoracic and Vascular Anesthesia 35: 2662–68

The mean duration of VA ECMO was 7.1 days (range 0 to 39). Multivariate logistic regression showed that prolonged duration of VA ECMO therapy (4 to 7 days: adjusted rate 54%, OR 0.28, 95% CI 0.18 to 0.44; 8 to 10 days: adjusted rate 61%, OR 0.51, 95% CI 0.29 to 0.87; and more than 10 days: adjusted rate 59%, OR 0.49, 95% CI 0.31 to 0.81) was associated with lower risk of mortality compared with VA ECMO lasting 3 days or less (adjusted rate 78%). Patients needing VA ECMO therapy for 8 to 10 days (OR 1.96, 95% CI 1.15 to 3.33) and more than 10 days (OR 1.85, 95% CI 1.14 to 3.02) had statistically significantly higher mortality compared with those on VA ECMO for 4 to 7 days.

Study focuses on association between duration of VA ECMO and mortality.

Mariscalco G, Salsano A, Fiore A et al. (2020) Peripheral versus central extracorporeal membrane oxygenation for postcardiotomy shock: Multicenter registry, systematic review, and meta-analysis. Journal of Thoracic and Cardiovascular Surgery 160: 1207-1216.e44

Pooled prevalence of in-hospital and 30-day mortality in overall patient population was 67% (95% CI 64.7 to 68.4%), and pooled unadjusted risk ratio analysis confirmed that people having peripheral VA ECMO had a lower in-hospital and 30-day mortality than those who had central cannulation (risk ratio, 0.92; 95% CI 0.87 to 0.98).

Study focuses on cannulation strategy.

Menon PR, Flo Forner A, Marin-Cuartas M et al. (2021) 30-Day perioperative mortality following venoarterial extracorporeal membrane oxygenation for postcardiotomy cardiogenic shock in patients with normal preoperative ejection fraction. Interactive Cardiovascular and Thoracic Surgery 32: 817-824

71 (41%) people presented PCCS caused by coronary malperfusion and in 102 (59%) no evident cause was found for PCCS. Median duration of VA ECMO support was 5 days. 135 (78%) people presented VA ECMO related complications, and the overall 30-day perioperative mortality was 58%. Independent predictors of mortality were lactate level just before VA ECMO implantation (OR 1.27; p<0.001), major bleeding during VA ECMO (OR 3.76; p=0.001), prolonged cardiopulmonary bypass time (OR 1.01; p<0.001) and female gender (OR 4.87; p<0.001).

Small study, focusing on outcomes in people with normal preoperative ejection fraction.

Melehy A, Ning Y, Kurlansky P et al. (2022) Bleeding and thrombotic events during extracorporeal membrane oxygenation for postcardiotomy shock. The Annals of Thoracic Surgery 113(1): 131-137

Of the 152 patients who received ECMO for postcardiotomy shock, 33 (23%) had 40 thrombotic events and 64 (45%) had 86 bleeding events.

Studies with more relevant outcomes were included.

Mihu MR, El Banayosy AM, Harper MD et al. (2024) Comparing outcomes of post-cardiotomy cardiogenic shock patients: on-site cannulation vs. retrieval for V-A ECMO support. Journal of Clinical Medicine 13(11): 3265

Single centre retrospective study, USA

n=121

Follow-up: In-hospital

The overall mortality rate was 52%. Of the patients who died (n=63), 50 experienced on-ECMO mortalities, and 13 had post-weaning mortalities. The ECLS weaning rate was 55% (n=34) in the retrieved group and 63% (n=37) in the on-site group (p=0.38).

Outcomes not reported as overall population, but by subgroup: cannulation on or off site.

Papadopoulos N, Marinos S, El-Sayed Ahmad A et al. (2015) Risk factors associated with adverse outcome following extracorporeal life support: Analysis from 360 consecutive patients. Perfusion 30(4): 284-290

ECLS weaning was successful in 58% and 30% could be discharged from hospital. The main cause of death was sepsis (69%). Overall, major cerebrovascular events occurred in 12% (bleeding 3%, embolic 9%), limb ischaemia in 13%, GI complications in 16% and RRT in 61%. Kaplan Meier estimates for long-term survival were 26% at one year and 22% at 5 years.

Included in Kowalewski (2020), Biancari (2018), Alba (2021) SLRs.

Provaznik Z, Philipp A, Zeman F et al. (2021) Extracorporeal life support in postcardiotomy cardiogenic shock: a view on scenario, outcome, and risk factors in 261 patients. The Thoracic and Cardiovascular Surgeon 69(3): 271-278

Single centre retrospective study, Germany

n=261

Follow-up: median 3.2 years

Overall mortality on ECLS was 39%. Overall follow-up survival was 24%.

Larger studies with longer follow-up included.

Qi J, Yan W, Liu G et al. (2023) Evaluation of Acute Kidney Injury in Postcardiotomy Cardiogenic Shock Patients Supported by Extracorporeal Membrane Oxygenation. Reviews in Cardiovascular Medicine 24: a36

The incidence of acute kidney injury (AKI) 3 or higher was 59%. People with AKI 3 or higher needed significantly longer mechanical ventilation and hospital stay. Intraoperative implantation VA ECMO was associated with a decreased incidence of AKI 3 or higher.

Small study, focusing on acute kidney injury.

Radwan M, Baghdadi K, Popov AF et al. (2023) Right Axillary Artery Cannulation for Veno-Arterial Extracorporeal Membrane Oxygenation in Postcardiotomy Patients: A Single-Center Experience.

Medicina 59 (no. 11)

Successful weaning=49%

In-hospital survival=35%

46 (26%) people were alive after 1-year follow-up.

In people with acute LV dysfunction after cardiothoracic surgery who cannot be weaned from cardiopulmonary bypass, right axillary artery cannulation is a safe and reliable method for VA ECMO support with an acceptable complication rate.

Small study, focusing on right axillary artery cannulation for VA ECMO.

Raffa GM, Kowalewski M, Brodie D, Ogino M et al. (2019) Meta-Analysis of Peripheral or Central Extracorporeal Membrane Oxygenation in Postcardiotomy and Non-Postcardiotomy Shock.

The Annals of Thoracic Surgery 107: 311-321

The peripheral approach was more commonly used (58%) than the central one. There was no difference in the analysis between the 2 techniques regarding all-cause mortality RR (1.00, 95% CI 0.94 to 1.08, I²=0%, p=0.92).

Peripheral cannulation was associated with a statistically significant reduction in the risk of bleeding (p=0.02), continuous venovenous hemofiltration (p=0.03), transfusion of red blood cells units (p<0.00001), fresh frozen plasma units (p=0.0002), and platelet units (p<0.00001).

More recent systematic reviews are included.

Saha A, Kurlansky P, Ning Y et al. (2021) Early venoarterial extracorporeal membrane oxygenation improves outcomes in post-cardiotomy shock.

Journal of Artificial Organs 24: 7-14

Overall, outcomes of ECMO for post-cardiotomy shock improved over the study period. The survival benefit appears to be associated with earlier ECMO initiation before prolonged hypoperfusion occurs.

Studies with more people or longer follow-up are included.

Sahli SD, Kaserer A, Braun J et al. (2022) Predictors associated with mortality of extracorporeal life support therapy for acute heart failure: single-center experience with 679 patients. Journal of Thoracic Disease 14(6): 1960-1971

In-hospital mortality significantly varied between ECLS indications: 71% (152/215) for postcardiotomy, 68% (108/159) for cardiopulmonary resuscitation, 47% (110/234) for refractory cardiogenic shock, and 10% (7/71) for lung transplantation and expansive thoracic surgery (p<0.001).

Larger studies split by cardiogenic shock aetiology were included.

Schaefer A-K, Latus M, Riebandt J et al. (2023) Bleeding and thrombotic events in post-cardiotomy extracorporeal life support.

European Journal of Cardio-thoracic Surgery 63 (no. 4)

196 people (39%) had 235 bleeding events.

Overall mortality was higher in people with major bleeding complications than in those without bleeding complications (p<0.0001). 246 people (49%) had at least 1 haemocompatibility-related adverse event.

Retrospective study focused on bleeding and thrombotic events.

Schaefer A-K, Distelmaier K, Riebandt J et al. (2022) Access site complications of postcardiotomy extracorporeal life support.

The Journal of Thoracic and Cardiovascular Surgery 164: 1546-1558e8

Although survival did not differ, surgeons should be aware of access-site-specific complications when choosing peripheral PC-ECLS access. Although lower rates of limb ischaemia and the advantage of antegrade flow seem beneficial for axillary cannulation, the high incidence of right hemispheric strokes in axillary artery cannulation should be considered.

Retrospective study focused on assessing the influence of primary arterial access.

Schaefer A-K, Riebandt J, Bernardi MH et al. (2022) Fate of patients weaned from post-cardiotomy extracorporeal life support.

European Journal of Cardio-thoracic Surgery 61: 1178-1185

358 patients were successfully separated from ECLS and survived for more than 24 hours (352 weaned from ECLS, 3 transitioned to durable left ventricular assist device and 3 transitioned to a heart transplant). A total of 36% of patients who were successfully weaned from ECLS did not survive until hospital discharge. In-hospital deaths of the whole cohort were 52%. For those who survived to discharge (n=231), survival was 87% after 1 year and 69% after 5 years.

Longer ECLS duration, older age, female gender and lower preoperative

glomerular filtration rate were independently associated

with in-hospital death after successful ECLS weaning.

Retrospective study focused on the outcomes for people who were weaned from post-cardiotomy ECLS.

Shao J, Shao C, Wang Y et al. (2023) The low hemoglobin levels were associated with mortality in post-cardiotomy patients undergoing venoarterial extracorporeal membrane oxygenation

Perfusion DOI: 10.1177/

02676591231193987

Survival=45%. Those who survived were younger than those who died (58 versus 63, p=0.023).

Low haemoglobin levels at day 1 were independently associated with in-hospital mortality.

Small retrospective study focusing on the impact of low haemoglobin levels.

Shao C, Wang L, Yang F et al. (2022) Quality of life and mid-term survival in patients receiving extracorporeal membrane oxygenation after cardiac surgery. ASAIO Journal 68(3): 349-355

The SF-36 scores in general health and vitality were significantly lower among the ECMO survivors (p<0.05). After discharge, ECMO versus non-ECMO survival (93% versus 82%; p=0.013).

Studies with more relevant outcomes were included.

Tantway TM, Arafat AA, Albabtain MA et al. (2023) Sepsis in postcardiotomy cardiogenic shock patients supported with veno- arterial extracorporeal membrane oxygenation.

The International Journal of Artificial Organs 46: 153-161

High body mass index and CABG were associated with sepsis. Preoperative dialysis and IABP predicted sepsis. Patients with ECMO-associated sepsis tended to have a higher blood transfusion after surgery, with a trend of a higher rate of re-exploration.

Small retrospective study assessing predictors of sepsis and its effect on outcomes after ECMO.

Terrazas JA, Stadlbauer AC, Li J et al. (2024) Age-Related Quality of Life in Cardiac Surgical Patients with Extracorporeal Life Support. The Thoracic and Cardiovascular Surgeon 72: 530–38

Overall survival-to-discharge was 32% (n=63), with better survival in the younger group (young=39%; old=22%, p=0.01). 42 people (66%) responded to the QoL survey after a median follow-up of 4.3 years. Older people reported more problems with mobility (young=52%; old=88%, p=0.02) and self-care (young=24%; old=76%, p=0.01). However, the self-rated health status using the Visual Analogue Scale showed no differences (70% for both, p=0.38). Likewise, the comparison with an age-adjusted German reference population showed similar QoL indices.

Studies with more people or longer follow-up are included.

Tian X, Wang L, Li C et al. (2024) Combining the vasoactive-inotropic score with lactate levels to predict mortality in post-cardiotomy patients supported with venoarterial extracorporeal membrane oxygenation.

European Journal of Cardio-thoracic Surgery 66 (no. 3)

139 people (62%) were weaned from VA ECMO, and 104 (47%) survived to hospital discharge.

Among patients with PCS needing VA ECMO, the initiation before reaching a vasoactive-inotropic score (VIS) above 24.3 and lactate levels higher than 6.85 mmol/litre was associated with improved in-hospital and 30-day outcomes, suggesting that the combined assessment of the VIS and lactate levels may be instructive for determining the initiation of VA ECMO.

Small retrospective study determining the predictive role of the combined assessment of the vasoactive-inotropic score (VIS) and lactate levels.

Toivonen F, Biancari F, Dalen M et al. (2021) Neurologic Injury in Patients Treated With Extracorporeal Membrane Oxygenation for Postcardiotomy Cardiogenic Shock.

Journal of Cardiothoracic and Vascular Anesthesia 35: 2669-2680

Overall, neurological injury occurred in 19% of people in the overall series, but the proportion ranged from 0% to 65% among the centres. Ischaemic stroke occurred in 84 people and haemorrhagic stroke in 47 people. Emergency procedure was the sole independent predictor of neurological injury. In-hospital mortality was higher in those with neurological injury than those without (79% versus 61%, p<0.001). The 1-year survival was lower in the neurological injury group (17% versus 37%). Long-term survival did not differ between people with ischaemic stroke and those with haemorrhagic stroke.

Main outcomes from the registry are included in a separate paper (Biancari 2020).

Xie H, Yang F, Hou D et al. (2020) Risk factors of in-hospital mortality in adult postcardiotomy cardiogenic shock patients successfully weaned from venoarterial extracorporeal membrane oxygenation. Perfusion 35(5): 417-426

Single centre retrospective study, China

n=363

Follow-up: In-hospital

In total, 212 (58%) of 363 postcardiotomy cardiogenic shock patients were successfully weaned from venoarterial extracorporeal membrane oxygenation.

Studies with more relevant outcomes and larger studies with longer follow-up were included.

Yang F, Hou D, Wang J et al. (2018) Vascular complications in adult postcardiotomy cardiogenic shock patients receiving venoarterial extracorporeal membrane oxygenation. Annals of Intensive Care 8: 72

252 people (58%) were weaned off VA ECMO and 153 (35%) survived to discharge. Major vascular complications were seen in 72 patients (17%), including bleeding or haematoma in the cannulation site (9%), limb ischaemia needing fasciotomy (9%), femoral artery embolism (1%), and retroperitoneal bleeding (1%). The rate of survival to discharge was 17% and 39% in people with or without major vascular complications, respectively (p<0.001).

Studies with more people or longer follow-up are included.

Zhigalov K, Sa MPBO, Safonov D et al. (2020) Clinical outcomes of venoarterial extracorporeal life support in 462 patients: Single-center experience. Artificial Organs 44(6): 620-627

Single centre retrospective study, Germany

n=462 (postcardiotomy n=357)

Follow-up: In-hospital

Overall, the in-hospital survival rate was 26%. There was no statistically significant difference between the groups: 26% for PCS and 25% for non-PCS, respectively. Weaning from VA-ECLS was possible in 44% for PCS and in 30% for non-PCS (p=0.004).

Larger studies split by CS aetiology were included.