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Twenty Year Experience with Urgent Percutaneous Cardiopulmonary Bypass for Salvage of Potential Survivors of Refractory Cardiovascular Collapse
*Walter P Dembitsky, Koteswara R Alla, Bryan Ortiz, Dale Glaser, Cynthia Walsh, Suzanne Chillcott, Marcia Stahovich, Robert Adamson, Sam Baradarian, Joe Chammas, Brian Jaski
Sharp Memorial Hospital, San Diego, CA
BACKGROUND: In-hospital cardiac arrest or refractory shock carries a high mortality despite the use of advanced resuscitative measures. We have implemented an in hospital, nurse based, continuously available percutaneaous veno- arterial cardiopulmonary bypass (ECLS) as an adjunct to resuscitation when initial measures are ineffective
METHODS:: In 1986, a system for the rapid initiation of ECLS was created where trained critical care nurses primed an ECLS circuit and in-house physicians percutaneously placed required cannulas. From a prospective registry, we assessed long-term survival (LTS) (greater than thirty days, CPS weaned), short-term survival (up to 30 days, CPS weaned), or death-on-CPS.
RESULTS:One hundred fifty patients (age: 57+17 years) were urgently placed on CPS for cardiac arrest (n=127) and refractory shock (n=23). Sixty-nine patients were weaned from CPS and 81 could not be weaned. Overall, 41 patients (27.3%) achieved LTS with a subsequent Kaplan-Meier survival T1/2 of 6.0 years. Duration of CPS support was 32+38 hours for LTS and 21+38 hours for non-LTS (NS). LTS occurred in 30/124(24.2%) placed on CPS for witnessed cardiac arrest, 0/3(0%) for unwitnessed cardiac arrest, and 11/23(47.8%) for refractory shock (p<0.05). In patients with CPS initiated in the cardiac catheterization laboratory, LTS was seen in 23/47 (48.9, %) versus 18/103 (17.5%) in other locations (p<0.001). In cardiac arrest patients with documented durations of CPR, LTS was achieved in 16/54 (29.6%) who received less than 30 minutes of CPR, and in 9/54 (16.7%) who received 30 minutes or more of CPR(NS). Most common etiology of death on CPS was refractory cardiac dysfunction (39.5%) and with short-term survival was neurological/pulmonary dysfunction (53.6%). Six patients were bridged to LVAD while five subsequently received heart transplantation. Multivariate analysis revealed only cath lab site of initiation as a significant independent predictor of LTS.(p<.05). survival was less with ECLS Flow >2L/mim/m2.During the 20y experience recipients have become younger , pre arrest insertion more common, time on support longer, and LTS has not changed .
CONCLUSIONS: More than half of resuscitated patients weaned from CPS had LTS. Rapid initiation of CPS permits LTS for some in-patients with cardiovascular collapse when initial advanced resuscitation fails. Strategies to improve end-organ function associated with use of CPS should lead to greater LTS. This practical application of inexpensive available technology should be more widely used.
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