Autopsy and clinical discrepancies in patients undergoing extracorporeal membrane oxygenation: a case series

Abstract

Background: Extracorporeal life support is used as a salvage procedure to treat refractory cardiopulmonary failure. There are limited data addressing discrepancies between pre- and postmortem findings in patients undergoing extracorporeal membrane oxygenation (ECMO). We investigated discrepancies between clinical and autopsy findings in patients placed on ECMO to assess in what proportion of patients were there significant cardiovascular or other pathologies present that were not clinically apparent prior to death.

Methodology: After institutional review board approval, a list of deceased ECMO patients who underwent autopsy examination from 2004 through 2015 was obtained from our institutional database. Retrospective analyses of findings on clinical investigations done while patients were on ECMO and findings on autopsy examination were compared and stratified according to modified Goldman Criteria, which classify discrepancies into four grades depending on their impact on patient's management and mortality.

Results: Of 19 patients, 18 patients had venoarterial ECMO (9 central + 5 peripheral + 4 conversions of ECMO type) and 1 patient received venovenous ECMO. Clinically unrecognized findings were found on autopsy in all patients. 56.6% of total discrepancies found were major [class I/II; e.g., myocardial infarction (MI), intracranial bleeding]. All patients had major discrepancies (class I/II) with an average of 4.21 class I discrepancies per patient. Class I discrepancies are findings which could have altered the course of treatment and survival of the patient if recognized premortem. The most common discrepancies were cardiovascular (MI 63.2%, marked cardiac remodeling 42.1%, severe coronary disease 31.6%) in nature across four classes of discrepancies.

Conclusions: We found major discrepancies between premortem and postmortem diagnoses in patients who underwent ECMO. Our findings underscore difficulties in clinically diagnosing events on ECMO as well as the need for enhanced surveillance and better diagnostic techniques in ECMO patients. Further prospective studies are necessary to understand effects of ECMO on major organs.

Keywords: Autopsy discrepancy; Clinical discrepancy.