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. 2024 Feb 6;13(3):e032288.
doi: 10.1161/JAHA.123.032288. Epub 2024 Jan 19.

Timing of Initiation of Extracorporeal Membrane Oxygenation Support and Outcomes Among Patients With Cardiogenic Shock

Jacob C Jentzer  1 , Stavros G Drakos  2 , Craig H Selzman  3 , Clark Owyang  4 , Felipe Teran  4 , Joseph E Tonna  3   5
Affiliations

Timing of Initiation of Extracorporeal Membrane Oxygenation Support and Outcomes Among Patients With Cardiogenic Shock

Jacob C Jentzer et al. J Am Heart Assoc. .

Abstract

Background: Venoarterial extracorporeal membrane oxygenation (ECMO) provides full hemodynamic support for patients with cardiogenic shock, but optimal timing of ECMO initiation remains uncertain. We sought to determine whether earlier initiation of ECMO is associated with improved survival in cardiogenic shock.

Methods and results: We analyzed adult patients with cardiogenic shock who received venoarterial ECMO from the international Extracorporeal Life Support Organization (ELSO) registry from 2009 to 2019, excluding those cannulated following an operation. Multivariable logistic regression evaluated the association between time from admission to ECMO initiation and in-hospital death. Among 8619 patients (median, 56.7 [range, 44.8-65.6] years; 33.5% women), the median duration from admission to ECMO initiation was 14 (5-32) hours. Patients who had ECMO initiated within 24 hours (n=5882 [68.2%]) differed from those who had ECMO initiated after 24 hours, with younger age, more preceding cardiac arrest, and worse acidosis. After multivariable adjustment, patients with ECMO initiated >24 hours after admission had higher risk of in-hospital death (adjusted odds ratio, 1.20 [95% CI, 1.06-1.36]; P=0.004). Each 12-hour increase in the time from admission to ECMO initiation was incrementally associated with higher adjusted in-hospital mortality rate (adjusted odds ratio, 1.06 [95% CI, 1.03-1.10]; P<0.001). The association between longer time to ECMO and worse outcomes appeared stronger in patients with lower shock severity.

Conclusions: Longer delays from admission to ECMO initiation were associated with higher a mortality rate in a large-scale, international registry. Our analysis supports optimization of door-to-support time and the avoidance of inappropriately delayed ECMO initiation.

Keywords: cardiogenic shock; extracorporeal membrane oxygenation; heart assist; mechanical circulatory support; outcomes; shock.

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Figures

Figure 1
Figure 1. Flow diagram demonstrating inclusion and exclusion criteria for the final study population, with the distribution of time from admission to extracorporeal membrane oxygenation (ECMO) initiation and associated in‐hospital death.
CS indicates cardiogenic shock; ECPR, extracorporeal cardiopulmonary resuscitation; ELSO, Extracorporeal Life Support Organization; VA, venoarterial; and VAD, ventricular assist device.
Figure 2
Figure 2. In‐hospital death in patients with early (within 24 hours of admission) or late (>24 hours after admission) ECMO initiation as a function of cardiac arrest, number of vasopressors, MCS use, and SCAI shock stage before ECMO initiation.
ECMO indicates extracorporeal membrane oxygenation; MCS, mechanical circulatory support; and SCAI, Society for Cardiovascular Angiography and Interventions.
Figure 3
Figure 3. In‐hospital death as a function of time from admission to extracorporeal membrane oxygenation (ECMO) initiation in patients with and without preceding cardiac arrest.
Figure 4
Figure 4. In‐hospital death (A) and native heart survival (B) as a function of time from admission to extracorporeal membrane oxygenation (ECMO) initiation in the entire cohort via locally estimated scatterplot smoother curves.
See this image and copyright information in PMC

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