Implementation of Venoarterial Extracorporeal Membrane Oxygenation in Nonintubated Patients

Abstract

Background: Although extracorporeal membrane oxygenation (ECMO) is generally performed percutaneously, the technology is deployed under sedation and necessitates endotracheal intubation. However, in some patients, the use of venoarterial (VA) ECMO without intubation may be beneficial. Herein, we describe our experiences with VA ECMO performed without prior endotracheal intubation.

Methods: A total of 783 patients treated with VA ECMO at a single center between January 2013 and July 2018 were reviewed retrospectively. We included patients who underwent successful VA ECMO implementation without prior endotracheal intubation, and excluded those who were younger than 18 years, had ongoing cardiopulmonary resuscitation status, and had poor quality of the vessels needed for percutaneous cannulation. The primary study outcome was in-hospital survival.

Results: In total, 50 patients were included in this study, 94% of whom showed cardiogenic shock. The mean age of the study participants was 56.3±14.5 years. The median VA ECMO support time was 7 days (range, 2-13 days). Twenty-one patients (42%) did not receive ventilator care during the VA ECMO support period, while 29 patients (58%) progressed to intubation after VA ECMO implementation. The rates of survival at discharge and weaning success were 82% (n=41) and 92% (n=46), respectively, and 80% (n=40) of patients presented good Glasgow-Pittsburgh Cerebral Performance Categories scores at discharge.

Conclusion: Even in patients with cardiogenic shock, percutaneous VA ECMO can be introduced safely without prior endotracheal intubation by an experienced care team. The application of nonintubated VA ECMO might be a feasible strategy in selected cases.

Keywords: Endotracheal; Extracorporeal membrane oxygenation; Intubation.

Fig. 1

Patient selection. From January 2013 to July 2018; in total, 783 patients were treated with ECMO implementation at SMC. SMC, Samsung Medical Center; ECMO, extracorporeal membrane oxygenation; E-CPR, extracorporeal cardiopulmonary resuscitation; VV, venovenous.

Fig. 2

Reasons for endotracheal intubation after VA ECMO implementation. In patients with nonintubated VA ECMO implementation, 29 patients underwent endotracheal intubation for the reasons shown above. Twelve patients underwent intubation for an operation (9 for heart transplantation, left ventricular assisted device implantation, or coronary artery bypass grafting and 3 for other operations), 6 for uncontrolled cardiac events, 4 due to respiratory failure, and 3 for sequential procedures (septal puncture procedures in the catheterization laboratory). VA ECMO, venoarterial extracorporeal membrane oxygenation.

Fig. 3

De-cannulation methods of VA ECMO. (A) Of the 50 total patients, 46 patients achieved weaning success from VA ECMO. De-cannulation of VA ECMO was performed by surgical removal in 20 patients (44%), device closure in 20 patients (44%), and manual compression in 6 patients (12%). (B) In the intubation group, de-cannulation of VA ECMO was performed by device closure in 16 patients (76%). VA ECMO, venoarterial extracorporeal membrane oxygenation.

Fig. 4

Kaplan-Meier curves for estimated 6-month (24-week) survival. (A) Analysis of all patients, (B) analysis according to progression to intubation, and (C) results of ACS and acute decompensated HF subgroup analysis. VA ECMO, venoarterial extracorporeal membrane oxygenation; ACS, acute coronary syndrome; HF, heart failure.