Article Abstract

Management of cardiac standstill on veno-arterial extracorporeal membrane oxygenation using a high flow strategy

Authors: Denis Huang, Nicholas Cavarocchi, Hitoshi Hirose

Abstract

Background: Cardiac standstill may be observedduring veno-arterial extracorporeal membrane oxygenation (VA-ECMO). Managementstrategies to decompress the heart include left-sided vent (LSV) insertion orhigh flows without LSV. However, evidence that either method reduces mortalityor neurological injury is unknown. In this study, we reviewed the outcomes ofpatients treated for cardiac standstill during ECMO with high flows instead ofLSV placement.
Methods: Among 189 patients who underwent VAECMO from 2010 to 2016, a total of 188 patients continued VA ECMO without LVSwhile on ECMO.  Retrospective chartreviews were performed focusing on cardiac standstill while on ECMO. Cardiacstandstill was defined as non-pulsatile arterial line tracing 6–8 hours aftercorrections of metabolic abnormalities. Patients who developed cardiacstandstill were studied for the duration of cardiac standstill and theirclinical outcomes.
Results: Twenty-two patients (12%) developedcardiac standstill during VA-ECMO. Nine (41%) survived ECMO therapy and 6 (27%)survived to discharge with full neurological recovery. Of the ECMO survivors,cardiac standstill was observed over 7 (range, 3–10) days and ECMO flow wasincreased by an average of 32%. Causes of death for non-ECMO survivors wereanoxic brain injury (3, 23%), ischemic stroke (4, 31%), hemorrhagic stroke (2,15%), sepsis (1, 7.7%), bleeding/disseminated intravascular coagulation (2,15%) and malignant arrhythmias (1, 7.7%). Cardiac standstill persisted untildeath in all non-survivors. Intraventricular thrombi developed duringstandstill in 6 patients (27%) and resolved in 3 patients after 5.7±3.5 days.Causes of death were related to pre-existing conditions and anticoagulationregimen, not thrombus formation. Survival of patients with and without thrombiwere similar (33% vs. 44%, P=0.999).
Conclusions: High ECMO flow adjustments can be aneffective alternative to LSV as a method of decompressing the heart, withoutincreasing neurological complications. With this strategy, patients diagnosedwith cardiac arrest during ECMO have reasonable survival outcomes (40%).