Extracorporeal membrane oxygenation for very high-risk transcatheter aortic valve implantation

Michael Seco; Paul Forrest; Simon A Jackson; Gonzalo Martinez; Sarah Andvik; Paul G Bannon; Martin Ng; John F Fraser; Michael K Wilson; Michael P Vallely

doi:10.1016/j.hlc.2014.05.006

Extracorporeal membrane oxygenation for very high-risk transcatheter aortic valve implantation

Heart Lung Circ. 2014 Oct;23(10):957-62. doi: 10.1016/j.hlc.2014.05.006. Epub 2014 May 27.

Authors

Affiliations

¹ Sydney Medical School, The University of Sydney, Sydney, Australia; The Baird Institute of Applied Heart & Lung Surgical Research, Sydney, Australia; Cardiothoracic Surgery Unit, Royal Prince Alfred Hospital, Sydney, Australia.
² Sydney Medical School, The University of Sydney, Sydney, Australia; Department of Anaesthesia, Royal Prince Alfred Hospital, Sydney, Australia.
³ School of Psychology, The University of Sydney, Sydney, Australia.
⁴ Cardiology Unit, Royal Prince Alfred Hospital, Sydney, Australia; Cardiology Department, Catholic University School of Medicine, Santiago, Chile.
⁵ The Baird Institute of Applied Heart & Lung Surgical Research, Sydney, Australia.
⁶ Sydney Medical School, The University of Sydney, Sydney, Australia; Cardiology Unit, Royal Prince Alfred Hospital, Sydney, Australia.
⁷ Critical Care Research Group, The Prince Charles Hospital, The University of Queensland.
⁸ The Baird Institute of Applied Heart & Lung Surgical Research, Sydney, Australia; Cardiothoracic Surgery Unit, Royal Prince Alfred Hospital, Sydney, Australia; Australian School of Advanced Medicine, Macquarie University, Sydney, Australia.
⁹ Sydney Medical School, The University of Sydney, Sydney, Australia; The Baird Institute of Applied Heart & Lung Surgical Research, Sydney, Australia; Cardiothoracic Surgery Unit, Royal Prince Alfred Hospital, Sydney, Australia; Australian School of Advanced Medicine, Macquarie University, Sydney, Australia. Electronic address: michael.vallely@bigpond.com.

PMID: 24954708
DOI: 10.1016/j.hlc.2014.05.006

Abstract

Background: Transcatheter aortic valve implantation (TAVI) can cause profound haemodynamic perturbation in the peri-operative period. Veno-arterial extracorporeal membrane oxygenation (ECMO) can be used to provide cardiorespiratory support during this time, either prophylactically or emergently.

Method: 100 TAVI procedures were performed between 2009 and 2013 in our institution. ECMO was used in 11 patients, including eight prophylactic and three rescue cases. Rescue ECMO was required for ventricular fibrillation after valvuloplasty, and aortic annulus rupture. The criteria for prophylactic ECMO included heart failure requiring stabilisation pre-TAVI, haemodynamic instability with balloon aortic valvuloplasty performed to improve heart function pre-TAVI, moderate or severe left and/or right ventricular failure, or borderline haemodynamics at procedure. Differences in preoperative characteristics and postoperative outcomes between ECMO and non-ECMO TAVI patients were compared, and significant results were further assessed controlling for EuroSCORE.

Results: Compared to TAVI patients who did not require ECMO, ECMO patients had significantly higher mean EuroSCORE (51 vs. 30%, p<.05). Postoperative outcomes, however, were largely comparable between the two groups. All-cause mortality occurred in nil prophylactic ECMO patients, one rescue ECMO patient, and two non-ECMO patients. The difference in mortality between ECMO and non-ECMO patients was not significantly different (9 vs. 2%; p>.05). ECMO patients were more likely to develop acute renal failure than non-ECMO patients (36 vs. 8%, p<.05), which was most likely due to haemodynamic collapse and end-organ dysfunction in patients that required ECMO rescue.

Conclusions: Instituting prophylactic ECMO in selected very high-risk patients may help avoid consequences of intra-operative complications and the need for emergent rescue ECMO.

Keywords: Aortic valve; Cardiac shock; Extracorporeal membrane oxygenation; Heart valve; Percutaneous; Replacement.

Copyright © 2014 Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ). Published by Elsevier B.V. All rights reserved.

MeSH terms

Acute Kidney Injury / etiology
Aged
Aged, 80 and over
Aortic Valve Stenosis / complications
Aortic Valve Stenosis / surgery*
Emergencies
Extracorporeal Membrane Oxygenation* / adverse effects
Female
Heart Failure / complications
Hemodynamics
Humans
Male
Prophylactic Surgical Procedures
Risk Assessment
Risk Factors
Transcatheter Aortic Valve Replacement* / adverse effects
Ventricular Fibrillation / etiology
Ventricular Fibrillation / therapy