Outcomes of patients with acute respiratory failure on veno-venous extracorporeal membrane oxygenation requiring additional circulatory support by veno-venoarterial extracorporeal membrane oxygenation

Rolf Erlebach; Lennart C Wild; Benjamin Seeliger; Ann-Kathrin Rath; Rea Andermatt; Daniel A Hofmaenner; Jens-Christian Schewe; Christoph C Ganter; Mattia Müller; Christian Putensen; Ruslan Natanov; Christian Kühn; Johann Bauersachs; Tobias Welte; Marius M Hoeper; Pedro D Wendel-Garcia; Sascha David; Christian Bode; Klaus Stahl

doi:10.3389/fmed.2022.1000084

Outcomes of patients with acute respiratory failure on veno-venous extracorporeal membrane oxygenation requiring additional circulatory support by veno-venoarterial extracorporeal membrane oxygenation

Front Med (Lausanne). 2022 Sep 23:9:1000084. doi: 10.3389/fmed.2022.1000084. eCollection 2022.

Authors

Rolf Erlebach¹, Lennart C Wild², Benjamin Seeliger³, Ann-Kathrin Rath⁴, Rea Andermatt¹, Daniel A Hofmaenner¹, Jens-Christian Schewe², Christoph C Ganter¹, Mattia Müller¹, Christian Putensen², Ruslan Natanov⁵, Christian Kühn^{5

6}, Johann Bauersachs^{6

7}, Tobias Welte^{3

6}, Marius M Hoeper^{3

6}, Pedro D Wendel-Garcia¹, Sascha David¹, Christian Bode², Klaus Stahl⁴

Affiliations

¹ Institute of Intensive Care Medicine, University Hospital Zurich, Zurich, Switzerland.
² Department of Anaesthesiology and Intensive Care Medicine, University Hospital Bonn, Bonn, Germany.
³ Department of Respiratory Medicine and German Centre of Lung Research (DZL), Hannover Medical School, Hanover, Germany.
⁴ Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hanover, Germany.
⁵ Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hanover, Germany.
⁶ German Research Foundation (DFG), Clinical Research Group (KFO 311): "(Pre)terminal Heart and Lung Failure: Unloading and Repair", Germany.
⁷ Department of Cardiology and Angiology, Hannover Medical School, Hanover, Germany.

Abstract

Objective: Veno-venous (V-V) extracorporeal membrane oxygenation (ECMO) is increasingly used to support patients with severe acute respiratory distress syndrome (ARDS). In case of additional cardio-circulatory failure, some experienced centers upgrade the V-V ECMO with an additional arterial return cannula (termed V-VA ECMO). Here we analyzed short- and long-term outcome together with potential predictors of mortality.

Design: Multicenter, retrospective analysis between January 2008 and September 2021.

Setting: Three tertiary care ECMO centers in Germany (Hannover, Bonn) and Switzerland (Zurich).

Patients: Seventy-three V-V ECMO patients with ARDS and additional acute cardio-circulatory deterioration required an upgrade to V-VA ECMO were included in this study.

Measurements and main results: Fifty-three patients required an upgrade from V-V to V-VA and 20 patients were directly triple cannulated. Median (Interquartile Range) age was 49 (28-57) years and SOFA score was 14 (12-17) at V-VA ECMO upgrade. Vasoactive-inotropic score decreased from 53 (12-123) at V-VA ECMO upgrade to 9 (3-37) after 24 h of V-VA ECMO support. Weaning from V-VA and V-V ECMO was successful in 47 (64%) and 40 (55%) patients, respectively. Duration of ECMO support was 12 (6-22) days and ICU length of stay was 32 (16-46) days. Overall ICU mortality was 48% and hospital mortality 51%. Two additional patients died after hospital discharge while the remaining patients survived up to two years (with six patients being lost to follow-up). The vast majority of patients was free from higher degree persistent organ dysfunction at follow-up. A SOFA score > 14 and higher lactate concentrations at the day of V-VA upgrade were independent predictors of mortality in the multivariate regression analysis.

Conclusion: In this analysis, the use of V-VA ECMO in patients with ARDS and concomitant cardiocirculatory failure was associated with a hospital survival of about 50%, and most of these patients survived up to 2 years. A SOFA score > 14 and elevated lactate levels at the day of V-VA upgrade predict unfavorable outcome.

Keywords: acute respiratory distress syndrome; extracorporeal life support (ECLS); sequential organ failure assessment (SOFA) score; shock; survival analysis; triple cannulation; vasoactive inotropic score.