Early ECMO Referral for Better Patient Prognosis
Used for decades as a tool in the treatment arsenal for cardiogenic shock, extracorporeal membrane oxygenation (ECMO) is being taken to a whole new level in about 100 shock programs in the United States, where unprecedented survival rates are beginning to be achieved.1 The best outcomes are seen when referra(ECMO) is being taken to a whole new level in about 100 shock programs in the United States, where unprecedented survival rates are beginning to be achieved to advanced cardiac medical therapies, such as ECMO, occurs earlier, rather than later, for certain patients.
Ideal candidates are in generally good health; the whole body has to make it through and have the capacity to heal. Feldman elaborates, “For instance, a patient who had a severe heart attack while at work, or one with suddenly worsened heart failure, or a healthy adult who was in a car accident; these people have a good chance of surviving and leading a long life if they receive ECMO, possibly paired with other treatments like dialysis, in a timely fashion. These therapies do the work, giving damaged organs a chance to rest and heal. For patients like these, referral for ECMO can’t occur too soon.”
According to David Feldman, MD, PhD, director of clinical services at the University of Cincinnati Medical Center Heart, Lung and Vascular Institute, “For patients with heart failure, physicians need to keep the criteria for cardiogenic shock on their radar and recognize the signs early.”
“The elegant simplicity of using ECMO for cardiogenic shock is that you take the failing heart out of the equation and support the patient’s circulation and organs while you attempt to correct the life threatening cardiac problem,” says Louis B. Louis IV, MD, FACS, associate professor, and chief of cardiac surgery. “With a patient on ECMO, you have the luxury of time to make a thoughtful decision, and once you decide to intervene, you are dealing with a patient whose organs are functioning instead of failing.”
With technological advances and refinements in ECMO protocols at quaternary care centers like the one at the University of Cincinnati Medical Center, even the most challenging cases may survive. Feldman notes, “With ECMO, we can bring a patient back even after 30 minutes of resuscitative efforts.” However, damage to the heart or other organ systems may yield a poor quality of life, with some patients requiring heart transplant or long-term hemodialysis.2 As with other types of advanced care, appropriate patient selection and good timing are key to achieving the best outcomes.
Diagnostic Criteria for Cardiogenic Shock3
- Systolic blood pressure <90 mm Hg for 30 minutes before inotropes/vasopressors OR Vasopressors or intra-aortic balloon pump are required to maintain systolic blood pressure ≥90 mm Hg
- Evidence of decreased organ perfusion
- Heart rate ≥60 beats per minute (including paced rhythms)
- Cardiac index <2.2 L/min/m2
- Pulmonary capillary wedge pressure elevated (≥15 mm Hg)
David Feldman, MD, PhD
Professor of Clinical Medicine
Director, Clinical Services, University of Cincinnati Medical Center Heart, Lung and Vascular Institute Heart, Lung and Vascular Institute
Director, Advanced Myocardial and Circulatory Services
Division of Cardiovascular Health and Disease
(513) 558-1167
feldmads@ucmail.uc.edu