OBJECTIVES: Age is the main determinant for mortality in patients requiring postcardiotomy extracorporeal membrane oxygenation (PC-ECMO), but strategies to reverse this trend are unknown. This study investigates PC-ECMO outcomes in older patients (≥70 years) compared with younger patients (<70 years). METHODS: This retrospective study included patients who required PC-ECMO between 2000 and 2020. Variables independently associated with in-hospital mortality were identified using mixed Cox proportional hazards models. RESULTS: The study included 2057 patients (mean age: 62.3 [first and third quartile: 19-94]; male patients: n = 1213 [59%]): 1376 (67%) were <70 years and 680 (33%) were ≥70 years old. Older patients had more preoperative comorbidities, whereas younger patients had lower cardiac function and more preoperative intubation and vasopressor use. In-hospital mortality was 56.3% (n = 775) and 68.8% (n = 468) in the <70 year and ≥70 year groups, respectively (P < .001). The 7-year postdischarge survival rate was greater for the younger patient group (P < .001). Variables associated with in-hospital mortality in older patients were previous stroke (hazard ratio [HR], 1.39; 95% confidence interval [CI], 1.05-1.84), preoperative right ventricular failure (HR, 1.45; 95% CI, 1-2.1), aortic surgery (HR 1.65; 95% CI, 1.2-2.2), and postoperative complications including bleeding (HR 1.24; 95% CI, 1.0-1.5), cardiac arrest (HR, 1.65; 95% CI, 1.3-2.1), and right ventricular failure (HR, 1.29; 95% CI, 1.0-1.6). CONCLUSIONS: PC-ECMO mortality is high in older patients. Preoperative factors including previous stroke and right ventricular failure and postoperative factors including bleeding, cardiac arrest, and right ventricular failure should be targeted to reduce in-hospital mortality after appropriate initial selection in older patients.

• Keywords
• age, cardiac surgery, extracorporeal membrane oxygenation, mechanical circulatory support, mortality, postcardiotomy cardiogenic shock,
• Publication type
• Journal Article MeSH

BACKGROUND: Cerebral perfusion may change depending on arterial cannulation site and may affect the incidence of neurologic adverse events in post-cardiotomy extracorporeal life support (ECLS). The current study compares patients' neurologic outcomes with three commonly used arterial cannulation strategies (aortic vs. subclavian/axillary vs. femoral artery) to evaluate if each ECLS configuration is associated with different rates of neurologic complications. METHODS: This retrospective, multicenter (34 centers), observational study included adults requiring post-cardiotomy ECLS between January 2000 and December 2020 present in the Post-Cardiotomy Extracorporeal Life Support (PELS) Study database. Patients with Aortic, Subclavian/Axillary and Femoral cannulation were compared on the incidence of a composite neurological end-point (ischemic stroke, cerebral hemorrhage, brain edema). Secondary outcomes were overall in-hospital mortality, neurologic complications as cause of in-hospital death, and post-operative minor neurologic complications (seizures). Association between cannulation and neurological outcomes were investigated through linear mixed-effects models. RESULTS: This study included 1897 patients comprising 26.5% Aortic (n = 503), 20.9% Subclavian/Axillary (n = 397) and 52.6% Femoral (n = 997) cannulations. The Subclavian/Axillary group featured a more frequent history of hypertension, smoking, diabetes, previous myocardial infarction, dialysis, peripheral artery disease and previous stroke. Neuro-monitoring was used infrequently in all groups. Major neurologic complications were more frequent in Subclavian/Axillary (Aortic: n = 79, 15.8%; Subclavian/Axillary: n = 78, 19.6%; Femoral: n = 118, 11.9%; p < 0.001) also after mixed-effects model adjustment (OR 1.53 [95% CI 1.02-2.31], p = 0.041). Seizures were more common in Subclavian/Axillary (n = 13, 3.4%) than Aortic (n = 9, 1.8%) and Femoral cannulation (n = 12, 1.3%, p = 0.036). In-hospital mortality was higher after Aortic cannulation (Aortic: n = 344, 68.4%, Subclavian/Axillary: n = 223, 56.2%, Femoral: n = 587, 58.9%, p < 0.001), as shown by Kaplan-Meier curves. Anyhow, neurologic cause of death (Aortic: n = 12, 3.9%, Subclavian/Axillary: n = 14, 6.6%, Femoral: n = 28, 5.0%, p = 0.433) was similar. CONCLUSIONS: In this analysis of the PELS Study, Subclavian/Axillary cannulation was associated with higher rates of major neurologic complications and seizures. In-hospital mortality was higher after Aortic cannulation, despite no significant differences in incidence of neurological cause of death in these patients. These results encourage vigilance for neurologic complications and neuromonitoring use in patients on ECLS, especially with Subclavian/Axillary cannulation.

• Keywords
• Cardiac arrest, Cardiac surgery, Extracorporeal membrane oxygenation, ICH, Neurologic complications, Stroke,
• MeSH
• Aorta * MeSH
• Femoral Artery * MeSH
• Subclavian Artery MeSH
• Adult MeSH
• Cardiac Surgical Procedures adverse effects   methods   MeSH
• Catheterization methods   adverse effects   statistics & numerical data   MeSH
• Middle Aged MeSH
• Humans MeSH
• Extracorporeal Membrane Oxygenation * methods   adverse effects   statistics & numerical data   MeSH
• Hospital Mortality trends   MeSH
• Nervous System Diseases etiology   epidemiology   MeSH
• Catheterization, Peripheral methods   adverse effects   statistics & numerical data   MeSH
• Postoperative Complications epidemiology   etiology   MeSH
• Retrospective Studies MeSH
• Aged MeSH
• Check Tag
• Adult MeSH
• Middle Aged MeSH
• Humans MeSH
• Male MeSH
• Aged MeSH
• Female MeSH
• Publication type
• Journal Article MeSH
• Multicenter Study MeSH
• Observational Study MeSH