ECMO in awake patients with acute cardiac failure as bridge to decision

Aims: In severe acute heart failure, the use of inotropes and intubation with mechanical ventilation is indicated and necessary according to ESC-guidelines. Surgical treatment options should be considered. However, postoperative outcome depends on patient condition prior to surgery and cardiac-related liver and/or renal failure, as well as mechanical ventilation are considered as unfavourable prognostic markers. We established a new strategy with veno-arterial extracorporal membrane oxygenation (ECMO) in fully awake patients with acute heart failure for cardiac stabilization and secondary-organ recovery as a safe “bridge to decision” before further invasive treatment is initiated.

Methods: Between July 2008 and March 2011, thirteen patients were diagnosed with severe cardiac failure refractory to conservative management and inotropic support and were treated subsequently with veno-arterial ECMO avoiding mechanical ventilation. An analysis of kidney and liver function as well as hemodynamic parameters and outcome was performed.

Results: A total of 13 patients (age 39.5±10.8 years) were placed on ECMO. Underlying diseases included right heart failure due to primary pulmonary hypertension (n=8), myocarditis (n=1) and graft failure following heart transplantation (n=4). Duration of ECMO support was 17.5±11.9 days. Hemodynamics stabilized immediately after ECMO initiation and inotropic support was reduced. Central venous saturation increased from 46.5±14.1% before ECMO to 69.0±9.1% (p<0.01) after stabilization. Similarly, the serum lactate decreased from 5.5±5.8mmol/l to 2.9±3.2mmol/l (p<0.01).

Secondary organ function improved dramatically after initiation of ECMO support, serum creatinine decreased from 103.3±29.4µmol/l to 70.7±29.8µmol/l on day 5 of ECMO therapy and a similar trend was detected in the course of serum transaminases: S-GOT decreased from 593.6±999.9U/l to 48.1±28.1U/l.

Ten patients were successfully bridged to transplantation, recovery or ventricular assist device implantation. Two patients died since no destination therapy was possible due to psychosocial reasons, one patient died due to a circulatory arrest during oxygenator exchange.

Conclusion: Awake ECMO in acute cardiac failure is a feasible therapy as a bridge to decision concept. This strategy avoids secondary complications coming along with sedation and mechanical ventilation and leads to recovery of secondary organ function enabling the respective destination therapy.