Incidence and predictors of weaning failure from veno-arterial extracorporeal membrane oxygenation therapy in patients with cardiogenic shock

A. Dettling (Hamburg)¹, C. Kellner (Hamburg)², J. Sundermeyer (Hamburg)², B. Beer (Hamburg)², L. C. Besch (Hamburg)², L. F. Bertoldi (Milan)³, S. Blankenberg (Hamburg)², J. Dauw (Ghent)⁴, D. Eckner (Nürnberg)⁵, I. Eitel (Lübeck)⁶, T. Graf (Lübeck)⁶, P. Horn (Mönchengladbach)⁷, J. Jozwiak-Nozdrzykowska (Leipzig)⁸, P. Kirchhof (Hamburg)⁹, S. Kluge (Hamburg)¹⁰, J. Krais (Regensburg)¹¹, D. von Lewinski (Graz)¹², A. Linke (Dresden)¹³, P. Lüdike (Osnabrück)¹⁴, E. Lüsebrink (Bonn)¹⁵, P. Nordbeck (Würzburg)¹⁶, F. Pappalardo (Alessandria)¹⁷, M. Pauschinger (Nürnberg)⁵, A. Proudfoot (London)¹⁸, T. Rassaf (Essen)¹⁹, H. Reichenspurner (Hamburg)²⁰, C. M. Sag (Regensburg)¹¹, C. Scherer (München)²¹, C. Schulze (Jena)²², R. H. G. Schwinger (Weiden i. d. Oberpfalz)²³, C. Skurk (Berlin)²⁴, M. Sramko (Prague)²⁵, G. Tavazzi (Bravia)²⁶, H. Thiele (Leipzig)⁸, N. Morici (Milano)²⁷, E. B. Winzer (Dresden)²⁸, D. Westermann (Freiburg im Breisgau)²⁹, N. Mangner (Dresden)²⁸, B. Schrage (Hamburg)^2
1Universitätsklinikum Hamburg-Eppendorf Klinik für Kardiologie Hamburg, Deutschland; ²Universitäres Herz- und Gefäßzentrum Hamburg Klinik für Kardiologie Hamburg, Deutschland; ³Cardio Center, Humanitas Clinical and Research Center – IRCCS, Rozzano, Milan, Italy Milan, Italien; ⁴Department of Cardiology, AZ Sint-Lucas Ghent, Belgien; ⁵Universitätsklinik der Paracelsus Medizinischen Privatuniversität Klinik für Innere Medizin 8, Schwerpunkt Kardiologie Nürnberg, Deutschland; ⁶Universitätsklinikum Schleswig-Holstein Medizinische Klinik II / Kardiologie, Angiologie, Intensivmedizin Lübeck, Deutschland; ⁷Städtische Kliniken Mönchengladbach GmbH Kardiologie & Angiologie Mönchengladbach, Deutschland; ⁸Herzzentrum Leipzig - Universität Leipzig Klinik für Innere Medizin/Kardiologie Leipzig, Deutschland; ⁹Universitäres Herz- und Gefäßzentrum Hamburg Klinik für Kardiologie Lübeck, Deutschland; ¹⁰University Medical Center Hamburg-Eppendorf, Department of Intensive Care Medicine, Hamburg, Germany Hamburg, Deutschland; ¹¹Universitätsklinikum Regensburg Klinik und Poliklinik für Innere Med. II, Kardiologie Regensburg, Deutschland; ¹²Medizinische Universität Graz Graz, Österreich; ¹³Herzzentrum Dresden GmbH an der TU Dresden Klinik für Innere Medizin und Kardiologie Dresden, Deutschland; ¹⁴Marienhospital Osnabrück Klinik für Innere Medizin / Kardiologie und Intensivmedizin Osnabrück, Deutschland; ¹⁵Universitätsklinikum Bonn Medizinische Klinik und Poliklinik II Bonn, Deutschland; ¹⁶Universitätsklinikum Würzburg Medizinische Klinik und Poliklinik I Würzburg, Deutschland; ¹⁷Dept Cardiothoracic and Vascular Anesthesia and Intensive Care, AO SS Antonio e Biagio e Cesare Arrigo Alessandria, Italien; ¹⁸Department of Perioperative Medicine, St. Bartholomew’s Hospital London, Großbritannien; ¹⁹Universitätsklinikum Essen Klinik für Kardiologie und Angiologie Essen, Deutschland; ²⁰Universitäres Herz- und Gefäßzentrum Hamburg Klinik und Poliklinik für Herz- und Gefäßchirurgie Hamburg, Deutschland; ²¹LMU Klinikum der Universität München Medizinische Klinik und Poliklinik I München, Deutschland; ²²Universitätsklinikum Jena Klinik für Innere Medizin I - Kardiologie Jena, Deutschland; ²³Kliniken Nordoberpfalz AG Medizinische Klinik II, Kardiologie Weiden i. d. Oberpfalz, Deutschland; ²⁴Charité - Universitätsmedizin Berlin CC 11: Med. Klinik für Kardiologie Berlin, Deutschland; ²⁵Department of Cardiology, IKEM Prague, Tschechische Republik; ²⁶Department of Clinical-Surgical, Diagnostic and Paediatric Sciences, University of Pavia Italy; Anesthesia and Intensive Care, Fondazione Policlinico San Matteo Hospital IRCCS Bravia, Italien; ²⁷IRCCS Fondazione Don Gnocchi, ONLUS, Santa Maria Nascente Milano, Italien; ²⁸Herzzentrum Dresden GmbH an der TU Dresden Klinik für Innere Medizin, Kardiologie und Intensivmedizin Dresden, Deutschland; ²⁹Universitäts-Herzzentrum Freiburg - Bad Krozingen Innere Medizin III, Kardiologie und Angiologie Freiburg im Breisgau, Deutschland

Background: Mortality in cardiogenic shock (CS) remains high even when mechanical circulatory support (MCS) restores adequate circulation. Despite extensive research efforts in recent years, evidence on MCS in this setting is so far neutral. Especially, weaning from MCS is a challenging aspect of daily MCS management and standardized guidance is not yet available.

Purpose: This study aims to investigate incidence and predictors of weaning failure from venoarterial extracorporeal membrane oxygenation (VA-ECMO) in patients with CS. 

Methods: Patients with CS treated with VA-ECMO at 23 tertiary-care centres in 7 countries were analysed. Weaning failure was defined as death during VA-ECMO support and death within two days after VA-ECMO explantation. To evaluate whether patient or treatment specific characteristics could serve as predictors for weaning success or failure multivariable logistic regressions models were fitted. 

Results: A total of 685 patients with CS treated with VA-ECMO were included in this study. Median age was 57 (IQR 49-66) years and 542 (79.1%) were male. More than half of the patients presented with CS due to acute myocardial infarction (AMI) (n=438, 63.9%) and prior cardiac arrest (n=431, 62.9%). Median lactate upon admission was 7.6 mmol/l (4.1-12.7). Of these, 410 patients (59.9%) were successfully weaned from VA-ECMO, whereas in 275 patients (40.1%) weaning failed. Of the successfully weaned patients 140 (36.1%) died before hospital discharge. The mortality of the overall cohort was 62.4%. AMI was slightly less common in patients with failed weaning. Age (Odds ratio (OR) 1.04, 95% confidence interval (CI): 1.02, 1.06; p<0.001) and cardiac arrest before VA-ECMO implantation (OR 1.68, 95%-CI: 1.09, 2.6; p=0.019) where the only baseline parameters associated with weaning failure. Lactate clearance within 24h after VA-ECMO initiation was associated with successful weaning (OR 0.13, 95%-CI: 0.07, 0.26; p<0.001, Figure 1). 

Conclusion: Despite successful deployment of VA-ECMO, patients with CS are still at a very high mortality risk during VA-ECMO treatment and even after successful weaning. Competing risks (e.g., higher age, prior cardiac arrest) might partially explain this. Importantly, all patients with VA-ECMO have sufficient end-organ and tissue perfusion, but only some show a fast and prognostically favourable lactate clearance. Therefore, efforts should be made to unravel which factors leverage the VA-ECMO provided perfusion into a persistent stabilization and recovery.

Figure 1: Predictors of weaning failure from VA-ECMO support in patients with cardiogenic shock.