Extracorporeal membrane oxygenation (ECMO) for acute heart failure in adults

Death during extracorporeal mechanical oxygenation (ECMO) support was reported in 40% (52 out of 131) of patients in a case series of 131 patients with cardiogenic shock; in 'most cases' this was because of multi-organ failure or sepsis.

Death within 30 days was reported in 76% (167 out of 219) of patients in the case series of 219 patients with refractory postcardiotomy cardiogenic shock; the main cause of death was low cardiac output syndrome secondary to refractory myocardial failure.

Intracranial haemorrhage was reported in 2% of patients in the register reporting on 2,312 cardiac failure patients (absolute numbers not reported; timing unclear).

Major or significant bleeding was reported to have a pooled incidence estimate of 41% (95% confidence interval [CI] 14.8% to 63.6%) in a systematic review of case series of 260 patients (5 studies).

Rethoracotomy for bleeding or tamponade was reported to have a pooled incidence estimate of 42% (95% CI 16.1% to 83.7%) in a systematic review of case series of 828 postcardiotomy patients (6 studies).

Stroke was reported in 9% (7 out of 81) of patients in the case series of 81 patients (timing unclear). A pooled incidence estimate of 6% (95% CI 4.2% to 8.3%) was reported for stroke in a systematic review of case series of 630 patients (3 studies).

Femoral artery perforation (leading to uncontrollable bleeding and subsequent death) was reported in 2 patients in the case series of 131 patients. Inferior vena cava tear was reported in 2% (2 out of 92) of patients in a systematic review of case series of 92 patients (2 studies).

Lower extremity amputation was reported to have a pooled incidence estimate of 5% (95% CI 2.3% to 9.3%) in a systematic review of case series of 192 patients (5 studies).

Fasciotomy or compartment syndrome was reported to have a pooled estimate of 10% (95% CI 7.35% to 14.5%) in a systematic review of case series of 335 patients (5 studies).

Lower extremity ischaemia was reported to have a pooled estimate of 17% (95% CI 12.5% to 22.6%) in a systematic review of case series of 677 patients (13 studies). Lower limb ischaemia was reported in 13% (28 out of 219) of patients in the case series of 219 patients; fasciotomy for severe leg ischaemia was needed in 6% (13 out of 219) of patients (timing unclear).

Venous thrombus in either the femoral vein or the inferior vena cava was reported in 8% (18 out of 217) of patients (4 studies) and arterial thrombus in 7% (13 out of 192) of patients (3 studies) in a systematic review of case series.

Significant post-ECMO infection had a pooled incidence estimate of 30% (95% CI 13.7% to 64.5%) in a systematic review of case series of 992 patients (10 studies). Significant infection was defined as sepsis or suspected sepsis needing antibiotics, which occurred in 8 of the 10 studies. Ventilator-associated pneumonia (1 or more episode) was reported in 49% (40 out of 81) of patients, surgical wound infections in 17% (14 out of 81) of patients, bacteraemia in 14% (11 out of 81) of patients, and catheter-related infections in 6% (5 out of 81) of patients in the case series of 81 patients (timing unclear).

Mechanical complications, including oxygenator failure (15%; 36% of these patients survived), cannula problems (4%; 27% survived), tubing rupture (less than 1%; none survived) and pump malfunction (less than 1%; 28% survived), were reported in cardiac failure patients (n=2,312) included in the register of patients treated by ECMO (absolute numbers not reported). Clots in the ECMO circuit were reported in 19% (56 out of 295) of patients and air embolus in 2% (5 out of 295) of patients in the case series of 295 patients.

Brachial plexus injury was reported in 2 case reports of patients treated with ECMO. One of these patients died 55 days later from multiple systemic complications. Symptoms improved at 4‑month follow-up in the other patient.

The specialist advisers said that anoxic neurological complications were additional adverse events reported in the literature. They listed the following anecdotal adverse events: intrathoracic bleeding, left ventricular thrombus formation and acute pulmonary injury.