Hellmuth R. Muller Moran, MD, Michael H. Yamashita, MDCM, MPH, FRCSC, and Rakesh C. Arora, MD, PhD, FRCSC
Central Message
Although stronger evidence and guidance are still needed in many areas, providers at all levels will benefit from this comprehensive handbook on postcardiotomy ECLS care.
See Article page 1287.
It is no secret that the use of extracorporeal life support (ECLS) has increased dramatically. According to the Extracorporeal Life Support Organization registry, 463 centers performed 15,875 ECLS runs in 2019 compared with 115 centers that performed 1743 ECLS runs in 2000.
1
Several documents have been produced to guide the care of patients on ECLS on diverse topics from percutaneous mechanical circulatory support2
to extracorporeal cardiopulmonary resuscitation,- Rihal C.S.
- Naidu S.S.
- Givertz M.M.
- Szeto W.Y.
- Burke J.A.
- Kapur N.K.
- et al.
2015 SCAI/ACC/HFSA/STS clinical expert consensus statement on the use of percutaneous mechanical circulatory support devices in cardiovascular care: endorsed by the American Heart Assocation, the Cardiological Society of India, and Sociedad Latino Americ.
J Am Coll Cardiol. 2015; 65: e7-e26
3
blood transfusion,- Panchal A.R.
- Berg K.M.
- Hirsch K.G.
- Kudenchuk P.J.
- Del Rios M.
- Cabañas J.G.
- et al.
2019 American Heart Association focused update on advanced cardiovascular life support: use of advanced airways, vasopressors, and extracorporeal cardiopulmonary resuscitation during cardiac arrest: an update to the American Heart Association guidelines.
Circulation. 2019; 140: e881-e894
4
and most recently the Coronavirus Disease 2019 pandemic.5
These efforts represent critical junctures in the care of their respective populations, because without suitable guidance there can be no progress. Until now, however, there has been minimal guidance on the care of patients in postcardiotomy cardiogenic shock, which occurs commonly and in whom outcomes are generally poor without mechanical support.- Shekar K.
- Badulak J.
- Peek G.
- Boeken U.
- Dalton H.J.
- Lovkesh Arora L.
- et al.
Extracorporeal life support organization coronavirus disease 2019 interim guidelines: a consensus document from an international group of interdisciplinary extracorporeal membrane oxygenation providers.
ASAIO J. 2020; 66: 707-721
The authors, representing the Extracorporeal Life Support Organization, European Association for Cardio-Thoracic Surgery, Society for Thoracic Surgery, and American Association for Thoracic Surgery, are to be congratulated for producing a comprehensive expert consensus document on postcardiotomy ECLS in adults.
6
This document discusses many aspects of preoperative, during, and post-ECLS care. Reasonable, well thought-out recommendations are provided for a variety of commonly encountered and a number of less commonly encountered—but no less important—scenarios. Although the procedure of initiating ECLS is often technically straightforward, it is in the multitude of perioperative possibilities, including reaching futility that the “art” of ECLS is truly found. Indeed, apart from the initial status at presentation, these are the elements that perhaps have the greatest bearing on a patient's ultimate course. Individuals who are involved with ECLS at any level will benefit greatly by considering the many recommendations contained herein and applying them to their practice when able.The difficulty with this document and with many areas of acute and critical cardiac surgical care is the relatively low level of evidence supporting most of the included statements. Although there is often a significant amount of anecdotal evidence on how best to manage these challenging patients, Level A evidence is sparse. This highlights the need for rigorous, prospective studies or randomized controlled trials in the population on ECLS. Acknowledging this can be difficult given these patients are critically ill and not easily recruited into randomized studies. Nonetheless, it remains incumbent on our field to perform well-designed studies in patients on ECLS and to report our findings. Only by these efforts will we be able to further improve the care that we provide standardized practices across the field and identify the areas most deserving of future initiatives.
ECLS in postcardiotomy patients has changed the field of cardiac surgery, yet there remain many unanswered questions regarding its use. This important opus serves as an essential document for our specialty, particularly with provision of the most up-to-date guidance for the use of valuable ECLS resources in the postcardiotomy patient. This document will doubtless be considered required reading and, along with the vade mecum—or handbook—included in the supplementary materials, an invaluable resource for providers of postcardiotomy ECLS care across the globe.
References
- ECLS Registry Report International Summary - July 2020.Extracorporeal Life Support Organization, Ann Arbor, MI2020
- 2015 SCAI/ACC/HFSA/STS clinical expert consensus statement on the use of percutaneous mechanical circulatory support devices in cardiovascular care: endorsed by the American Heart Assocation, the Cardiological Society of India, and Sociedad Latino Americ.J Am Coll Cardiol. 2015; 65: e7-e26
- 2019 American Heart Association focused update on advanced cardiovascular life support: use of advanced airways, vasopressors, and extracorporeal cardiopulmonary resuscitation during cardiac arrest: an update to the American Heart Association guidelines.Circulation. 2019; 140: e881-e894
- Transfusion thresholds for adult respiratory extracorporeal life support: an expert consensus document.Can J Cardiol. 2020; 36: 1550-1553
- Extracorporeal life support organization coronavirus disease 2019 interim guidelines: a consensus document from an international group of interdisciplinary extracorporeal membrane oxygenation providers.ASAIO J. 2020; 66: 707-721
- 2020 EACTS/ELSO/STS/AATS expert consensus on post-cardiotomy extracorporeal life support in adult patients.J Thorac Cardiovasc Surg. 2021; 161: 1287-1331
Article info
Publication history
Published online: November 24, 2020
Accepted:
November 17,
2020
Received in revised form:
November 15,
2020
Received:
November 15,
2020
Footnotes
Disclosures: R.C.A. has unrestricted grant from Pfizer Canada Inc, and has received honoraria from Abbott Nutrition and Edwards Lifesciences for work unrelated to this article. All other authors reported no conflicts of interest.
The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest.
Identification
Copyright
© 2020 by The American Association for Thoracic Surgery
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- 2020 EACTS/ELSO/STS/AATS expert consensus on post-cardiotomy extracorporeal life support in adult patientsThe Journal of Thoracic and Cardiovascular SurgeryVol. 161Issue 4
- PreviewPost-cardiotomy extracorporeal life support (PC-ECLS) in adult patients has been used only rarely but recent data have shown a remarkable increase in its use, almost certainly due to improved technology, ease of management, growing familiarity with its capability and decreased costs. Trends in worldwide in-hospital survival, however, rather than improving, have shown a decline in some experiences, likely due to increased use in more complex, critically ill patients rather than to suboptimal management.
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