TY - JOUR
AU - Simon, André R
AB - Abstract OBJECTIVES Post-cardiotomy cardiogenic shock (PCCS) results in substantial morbidity and mortality, whereas refractory cases require mechanical circulatory support (MCS). The aim of the study was to compare extracorporeal membrane oxygenation (ECMO) and ventricular assist devices (VADs) utilized in the management of PCCS. METHODS In total, 56 consecutive patients who developed PCCS from 2005 to 2014 required MCS as a bridge to decision—24 were supported with a VAD and 32 with an ECMO. Groups were compared with respect to pre- and intraoperative characteristics and early and long-term outcomes to evaluate the impact of the type of MCS on complications and survival. Data are mean ± standard deviation and median with quartiles. RESULTS EuroSCORE II was significantly higher in the VAD group than in the ECMO group (28 ± 20 vs 13 ± 16, P = 0.020) corresponding to significantly higher New York Heart Association (P = 0.031) class and Canadian Cardiovascular Society class (P = 0.040) in the cohort. The median duration of support was 10 (4–23) and 7 (4–10) days in the VAD and ECMO groups, respectively. There were no significant differences in ITU (P = 0.262), hospital stay (P = 0.193) and incidences of most postoperative complications. A significantly higher proportion of patients was successfully weaned/upgraded in the VAD group [13 (54%) vs 4 (13%), P = 0.048] with a trend towards higher discharge rate [9 (38%) vs 5 (16%), P = 0.061]. Overall cumulative survival in early follow-up [Breslow (Generalized Wilcoxon) P = 0.017] and long-term follow-up [Log-rank (Mantel-Cox) p = 0.015] was significantly better in the VAD group. CONCLUSIONS VAD and ECMO represent essential tools to support patients with PCCS. Our preliminary results might indicate some benefits of using VAD in this group of patients; however, this evidence should be further assessed in larger multicentre trials. Short-term ventricular assist , Extracorporeal membrane oxygenation , Post-cardiotomy cardiogenic shock , Mechanical circulatory assist , Survival INTRODUCTION The worsening risk profiles of patients undergoing cardiac surgery, especially increasing age, higher body mass index, redo procedures and complexity of surgeries, are responsible for the higher incidence and severity of post-cardiotomy cardiogenic shock (PCCS). PCCS occurs in patients undergoing surgery with cardiopulmonary bypass (CPB), most commonly as a result of myocardial stunning, with incidence up to 2–6% of all cardiac surgical procedures [1, 2]. Intra-aortic balloon pump (IABP) is the most common mechanical assist device used for the treatment of low cardiac output following cardiac surgery; however, the overall mortality of patients with PCCS receiving IABP remains substantially high, accounting for 27–52% [3, 4]. Despite IABP and inotropic support, a large cohort of patients with PCCS continue to have a refractory low cardiac output. In such patients, mechanical circulatory support (MCS) in the form of extracorporeal membrane oxygenation (ECMO) or short-term ventricular assist device (VAD) becomes imperative to maintain adequate circulation and wean the patient off CPB. ECMO in addition to the circulatory assist per se also offers respiratory support, which could be helpful in PCCS complicated by severe flash pulmonary oedema. Short-term VAD does not provide respiratory support; however, it is versatile in utilization, in the form of left, right or biventricular support. To choose a suitable type of MCS in refractory PCCS is a surgeon’s dilemma and remains debatable. We have compared outcomes in patients who developed PCCS depending on the type of MCS utilized. MATERIALS AND METHODS This is a retrospective study of prospectively collected data pertaining to PCCS patients supported on ECMO or VAD between the years 2005 and 2014 at the Harefield Hospital. This study was categorized as a service evaluation by the ethical committee of the Royal Brompton & Harefield NHS Foundation Trust and hence did not require ethical approval. A total of 56 consecutive patients with PCCS requiring short-term VAD or ECMO were included in the study regardless of perioperative status and severity of heart failure. Patients were selected for ventricular support based solely on the failure to be weaned from CPB or progressive post-cardiotomy cardiac failure shortly after arrival in the intensive care unit. If the first attempt to wean the patient from CPB was unsuccessful, volume optimization, pharmacological therapy and the search for surgically correctable problems were performed. MCS was introduced when peak arterial pressure was <90 mmHg, mean left atrial pressure was >18 mmHg and cardiac index was <1.8 l/min/m2, or fatal ventricular arrhythmia occurred repeatedly in spite of maximum pharmacological treatment and IABP support. The standard short-term VAD set at our institution includes the CentriMag® (Thoratec, CA, USA) centrifugal pump, motor and the CentriMag pump. The tube set of the ECMO circuit is phthalate free and coated with Rheoparin® (Medos®, Germany). The special in- and outflow Levitronix cannulas exit the skin under the sternal xiphoid process to be connected to tubing. A proportion of patients were awake for a reasonable time after extubation still being on MCS facilitating mobilization. A wake state on MCS was defined as spontaneous breathing and absent sedation on MCS for at least 24 h. Patient population The procedures after which MCS was introduced included isolated coronary artery bypass grafting (CABG) in 17 patients (30%), isolated aortic valve replacement in 12 patients (21%), isolated ascending aorta replacement in 5 patients (9%) and combined procedures in 22 patients (40%). Patients who underwent heart transplantation were not in the scope of the present study, as the requirement for MCS after heart transplantation is usually associated with primary graft dysfunction that may have different mechanisms and is usually ascribed to preservation problems or poor graft function. Of the 24 patients included in the VAD group, 17 patients (71%) received left ventricular support (LVAD), 2 patients (8%) received right ventricular support (RVAD), and 5 patients (21%) received bi-ventricular support (BIVAD). The choice of VAD versus ECMO implantation in the setting of biventricular failure particularly in cases without respiratory failure was based on the surgeon’s preference and experience. In our centre, there are several proponents of ECMO therapy and a number of advocates of VAD support. Ventricular assist device implantation technique Implantations were performed using the same access (median sternotomy) as for the cardiac surgery at the time of or in the early phase after cardiac surgery. For LVAD implantation, the inflow cannula was inserted into the left atrium at the junction of right pulmonary veins and the tip of the cannula was directed towards the mitral valve. The outflow cannula was inserted into the ascending aorta. For RVAD, the inflow cannula was placed in the right atrium and the outflow graft in the main pulmonary artery. All the cannulas were passed through separate skin incisions in the upper epigastric area in order to facilitate easy closure of the sternum [5]. Extracorporeal membrane oxygenation implantation technique ECMO was implanted either centrally or peripherally. Peripheral ECMO was established by either the percutaneous technique or the cut down technique in cases of difficult access. The femoral vessels preferably on the right side were used as an access for cannula insertion. The venous, distal perfusion and arterial cannulas were inserted by the Seldinger technique in that order. The arterial and the distal perfusion cannulas (DPCs) were connected via a ‘Y’ connector to an inflow arm of the ECMO. The pump was then started at low speed, gradually increasing the speed to achieve flows of 60 ml/kg/min. Central ECMO was established via the sternum utilizing the right atrium for inflow and the ascending aorta for outflow cannula. A left ventricular vent was inserted and connected to the outflow circuit of the ECMO in patients with dilated left ventricle following ECMO implantation. IABP inserted before ECMO implantation was continued post-ECMO for ventricular unloading and induction of pulsatility in ECMO flow [6]. Postoperative anticoagulation Intravenous unfractionated heparin infusion was commenced when the cumulative chest tube drainage was ≤50 ml/h for 4 consecutive hours, and coagulation parameters had returned to normal levels. Heparin was started at the rate of 500 U/kg/h and titrated to achieve an activated partial thromboplastin time ranging between 60 and 80 s. The level of factor anti-Xa was maintained at 0.2–0.7 U/ml. Weaning VAD/ECMO flows were reduced in gradual decrements of 1 l/min with haemodynamic stability. A cardiac index ≥2 l/min/m2 and a stable mean arterial pressure >60 mmHg with little or no increase in filling pressures were considered indicative of improving myocardial function for the possibility of device explantation. After these initial criteria were met, patients usually underwent echocardiography with similar decrements of inflow to visualize the ventricular function. Patients maintaining adequate haemodynamics and showing evidence of improving ventricular function with decreasing flows were considered for device explantation [5]. Study end points The primary end points were survival to myocardial recovery and device explantation or upgrade to a long-term VAD as well as estimated overall cumulative survival in the patients available for follow up. Secondary end points were early postoperative outcome variables, including incidences of common complications associated with MCS. Baseline haemodynamic status, laboratory measurements targeting end organ function and neurological status were noted before ECMO and short-term VAD implantation. Perioperative variables of VAD and ECMO were compared. Survival estimation over the follow-up ranging from device implantation till death or cut-off of the study was calculated and presented for 30 days, 6 months, 1, 2 and 4 years. Follow-up No patient was lost to follow-up. Follow-up time ranged from 0 to 2800 days. Statistical analysis All data were analysed using IBM SPSS Statistics for Windows, Version 21.0 (IBM Corp., Released 2012, Armonk, NY, USA). Continuous data were evaluated for normality using 1-sample Kolmogorov–Smirnov test and confirmed by histograms. Continuous variables were expressed as the mean ± standard deviation in cases of normally distributed variables or median (interquartile range) in cases of non-normally distributed variables. Categorical variables were presented as total numbers and percentages. Continuous data were analysed with the unpaired Student’s t-test for normally distributed variables and the Mann–Whitney U-test for non-normally distributed variables. Pearson’s χ2 or the Fisher’s exact tests were used for categorical data depending on the minimum expected count in each crosstab. The Kaplan–Meier survival analysis was performed to estimate early [Breslow (Generalized Wilcoxon) test] and long-term [log-rank (Mantel-Cox) test] survival after device implantation. Patients who survived at the cut-off of the study were censored. P-values <0.05 were considered statistically significant, whereas P-values ranging between 0.05 and 0.1 were considered a trend. RESULTS A total of 56 patients in PCCS who underwent implantation of MCS using either a short-term VAD (n = 24) or ECMO (n = 32) were included in this retrospective analysis of prospectively collected data. Preoperative demographics and baseline characteristics are presented in Table 1, and they comprise important clinical and laboratory parameters evaluating the preoperative clinical condition of both patient groups. There were no statistically significant differences in laboratory values, ejection fraction (P = 0.158) and demographic variables such as age (P = 0.120), gender (P = 0.645), height (P = 0.191) and weight (P = 0.602). However, in terms of further baseline clinical characteristics (Table 2), patients supported with VAD had significantly higher preoperative EuroSCORE II (28 ± 20 in the VAD group compared to 13 ± 16 in the ECMO group, P = 0.014), and they were associated with significantly higher New York Heart Association class (P = 0.031) and Canadian Cardiovascular Society class (P = 0.040). Also, significantly more patients from the VAD group had a history of previous median sternotomy undergoing redo surgery prior to MCS (58% vs 16% in the VAD and ECMO group, respectively, P = 0.001). Particularly, CABG was more frequently performed in the past in patients from the VAD group (54% vs 16%, P = 0.002). In terms of the urgency of cardiac surgery performed prior to the need for MCS (P = 0.065), patients from the VAD group were similarly often operated on in an emergency setting (38% vs 22%). The proportion of patients who were supported with an IABP at the time of implantation of MCS was statistically higher in the VAD group (P = 0.020). However, in terms of implantation timing, only 2 patients (8%) from the VAD group and 3 patients (9%) from the ECMO group received IABP prior to cardiac surgery (P = 1.000), whereas all remaining patients were supported after cardiac surgery due to difficulties in CPB weaning. Table 1: Demographic and preoperative baseline characteristics VAD (n = 24) ECMO (n = 32) P-value Age (years) 48 (38–59) 57 (45–68) 0.120 Female gender, n (%) 3 (13) 14 (44) 0.645 Height (cm), mean ± SD 175 ± 8 171 ± 12 0.191 Weight (kg), mean ± SD 80 ± 15 83 ± 21 0.602 Central approach, n (%) 24 (100) 23 (72) 0.007 Cross-clamp time (min), mean ± SD 127 ± 67 131 ± 80 0.873 CPB time (min), mean ± SD 200 ± 114 232 ± 160 0.511 Heart rate (bpm), mean ± SD 88 ± 12 92 ± 22 0.538 Mean arterial pressure (mmHg), median (IQR) 65 (57–80) 59 (53–63) 0.055 Central venous pressure (mmHg), median (IQR) 14 (10–19) 15 (13–25) 0.602 Lactate (mmol/l), median (IQR) 7 (2–14) 10 (6–13) 0.321 Urea (mmol/l), median (IQR) 7 (6–14) 7 (5–9) 0.306 Creatinine (mmol/l), median (IQR) 104 (88–172) 109 (82–130) 0.531 Bilirubin (mmol/l), median (IQR) 23 (18–33) 29 (20–70) 0.410 ALP (IU/l), median (IQR) 59 (32–132) 43 (33–70) 0.400 ALT (IU/l), median (IQR) 58 (42–78) 64 (33–276) 0.776 WBC (cells ×109/l), median (IQR) 14 (8–18) 11 (9–18) 0.827 CRP (mg/dl), median (IQR) 32 (9–202) 13 (5–140) 0.500 Ejection fraction (%), median (IQR) 32 (16–49) 40 (32–50) 0.158 VAD (n = 24) ECMO (n = 32) P-value Age (years) 48 (38–59) 57 (45–68) 0.120 Female gender, n (%) 3 (13) 14 (44) 0.645 Height (cm), mean ± SD 175 ± 8 171 ± 12 0.191 Weight (kg), mean ± SD 80 ± 15 83 ± 21 0.602 Central approach, n (%) 24 (100) 23 (72) 0.007 Cross-clamp time (min), mean ± SD 127 ± 67 131 ± 80 0.873 CPB time (min), mean ± SD 200 ± 114 232 ± 160 0.511 Heart rate (bpm), mean ± SD 88 ± 12 92 ± 22 0.538 Mean arterial pressure (mmHg), median (IQR) 65 (57–80) 59 (53–63) 0.055 Central venous pressure (mmHg), median (IQR) 14 (10–19) 15 (13–25) 0.602 Lactate (mmol/l), median (IQR) 7 (2–14) 10 (6–13) 0.321 Urea (mmol/l), median (IQR) 7 (6–14) 7 (5–9) 0.306 Creatinine (mmol/l), median (IQR) 104 (88–172) 109 (82–130) 0.531 Bilirubin (mmol/l), median (IQR) 23 (18–33) 29 (20–70) 0.410 ALP (IU/l), median (IQR) 59 (32–132) 43 (33–70) 0.400 ALT (IU/l), median (IQR) 58 (42–78) 64 (33–276) 0.776 WBC (cells ×109/l), median (IQR) 14 (8–18) 11 (9–18) 0.827 CRP (mg/dl), median (IQR) 32 (9–202) 13 (5–140) 0.500 Ejection fraction (%), median (IQR) 32 (16–49) 40 (32–50) 0.158 CPB: cardiopulmonary bypass; CRP: C reactive protein; IQR: interquartile range; SD: standard deviation; WBC: white blood count. Table 1: Demographic and preoperative baseline characteristics VAD (n = 24) ECMO (n = 32) P-value Age (years) 48 (38–59) 57 (45–68) 0.120 Female gender, n (%) 3 (13) 14 (44) 0.645 Height (cm), mean ± SD 175 ± 8 171 ± 12 0.191 Weight (kg), mean ± SD 80 ± 15 83 ± 21 0.602 Central approach, n (%) 24 (100) 23 (72) 0.007 Cross-clamp time (min), mean ± SD 127 ± 67 131 ± 80 0.873 CPB time (min), mean ± SD 200 ± 114 232 ± 160 0.511 Heart rate (bpm), mean ± SD 88 ± 12 92 ± 22 0.538 Mean arterial pressure (mmHg), median (IQR) 65 (57–80) 59 (53–63) 0.055 Central venous pressure (mmHg), median (IQR) 14 (10–19) 15 (13–25) 0.602 Lactate (mmol/l), median (IQR) 7 (2–14) 10 (6–13) 0.321 Urea (mmol/l), median (IQR) 7 (6–14) 7 (5–9) 0.306 Creatinine (mmol/l), median (IQR) 104 (88–172) 109 (82–130) 0.531 Bilirubin (mmol/l), median (IQR) 23 (18–33) 29 (20–70) 0.410 ALP (IU/l), median (IQR) 59 (32–132) 43 (33–70) 0.400 ALT (IU/l), median (IQR) 58 (42–78) 64 (33–276) 0.776 WBC (cells ×109/l), median (IQR) 14 (8–18) 11 (9–18) 0.827 CRP (mg/dl), median (IQR) 32 (9–202) 13 (5–140) 0.500 Ejection fraction (%), median (IQR) 32 (16–49) 40 (32–50) 0.158 VAD (n = 24) ECMO (n = 32) P-value Age (years) 48 (38–59) 57 (45–68) 0.120 Female gender, n (%) 3 (13) 14 (44) 0.645 Height (cm), mean ± SD 175 ± 8 171 ± 12 0.191 Weight (kg), mean ± SD 80 ± 15 83 ± 21 0.602 Central approach, n (%) 24 (100) 23 (72) 0.007 Cross-clamp time (min), mean ± SD 127 ± 67 131 ± 80 0.873 CPB time (min), mean ± SD 200 ± 114 232 ± 160 0.511 Heart rate (bpm), mean ± SD 88 ± 12 92 ± 22 0.538 Mean arterial pressure (mmHg), median (IQR) 65 (57–80) 59 (53–63) 0.055 Central venous pressure (mmHg), median (IQR) 14 (10–19) 15 (13–25) 0.602 Lactate (mmol/l), median (IQR) 7 (2–14) 10 (6–13) 0.321 Urea (mmol/l), median (IQR) 7 (6–14) 7 (5–9) 0.306 Creatinine (mmol/l), median (IQR) 104 (88–172) 109 (82–130) 0.531 Bilirubin (mmol/l), median (IQR) 23 (18–33) 29 (20–70) 0.410 ALP (IU/l), median (IQR) 59 (32–132) 43 (33–70) 0.400 ALT (IU/l), median (IQR) 58 (42–78) 64 (33–276) 0.776 WBC (cells ×109/l), median (IQR) 14 (8–18) 11 (9–18) 0.827 CRP (mg/dl), median (IQR) 32 (9–202) 13 (5–140) 0.500 Ejection fraction (%), median (IQR) 32 (16–49) 40 (32–50) 0.158 CPB: cardiopulmonary bypass; CRP: C reactive protein; IQR: interquartile range; SD: standard deviation; WBC: white blood count. Table 2: Risk factors and characteristics of cardiac surgery VAD (n = 24) ECMO (n = 32) P-value NYHA, n (%)  I 2 (8) 3 (10) 0.03  II 1 (4) 9 (28)  III 4 (17) 9 (28)  IV 17 (71) 11 (34) CCS, n (%)  1 3 (13) 1 (3) 0.04  2 2 (8) 12 (38)  3 4 (16) 7 (21)  4 15 (63) 12 (38) EuroSCORE II, mean ± SD 28 ± 20 13 ± 16 0.01 Risk factors, n (%)  IABP 15 (63) 10 (31) 0.02  Dialysis 7 (30) 14 (44) 0.265  Multiorgan failure 3 (13) 8 (25) 0.319  Diabetes mellitus (insulin dependent) 2 (8) 1 (3) 0.571  Previous myocardial infarction 10 (42) 15 (47) 0.698  Previous CABG/angioplasty 13 (54) 5 (16) 0.002  Previous sternotomy 14 (58) 5 (16) 0.001  Right ventricular failure 6 (24) 4 (13) 0.429 Urgency of cardiac surgery, n (%) 0.065  Routine 6 (24) 18 (56)  Urgent 9 (38) 7 (22)  Emergency 9 (38) 7 (22) Type of cardiac surgery, n (%) 0.179  CABG 9 (38) 8 (25)  Valve 7 (30) 5 (16)  Aorta 3 (12) 2 (6)  Mixed 5 (20) 17 (53) VAD (n = 24) ECMO (n = 32) P-value NYHA, n (%)  I 2 (8) 3 (10) 0.03  II 1 (4) 9 (28)  III 4 (17) 9 (28)  IV 17 (71) 11 (34) CCS, n (%)  1 3 (13) 1 (3) 0.04  2 2 (8) 12 (38)  3 4 (16) 7 (21)  4 15 (63) 12 (38) EuroSCORE II, mean ± SD 28 ± 20 13 ± 16 0.01 Risk factors, n (%)  IABP 15 (63) 10 (31) 0.02  Dialysis 7 (30) 14 (44) 0.265  Multiorgan failure 3 (13) 8 (25) 0.319  Diabetes mellitus (insulin dependent) 2 (8) 1 (3) 0.571  Previous myocardial infarction 10 (42) 15 (47) 0.698  Previous CABG/angioplasty 13 (54) 5 (16) 0.002  Previous sternotomy 14 (58) 5 (16) 0.001  Right ventricular failure 6 (24) 4 (13) 0.429 Urgency of cardiac surgery, n (%) 0.065  Routine 6 (24) 18 (56)  Urgent 9 (38) 7 (22)  Emergency 9 (38) 7 (22) Type of cardiac surgery, n (%) 0.179  CABG 9 (38) 8 (25)  Valve 7 (30) 5 (16)  Aorta 3 (12) 2 (6)  Mixed 5 (20) 17 (53) CABG: coronary artery bypass grafting; CCS: Canadian Cardiovascular Society; ECMO: extracorporeal membrane oxygenation; IABP: intra-aortic balloon pump; NYHA: New York Heart Association; SD: standard deviation; VAD: ventricular assist device. Table 2: Risk factors and characteristics of cardiac surgery VAD (n = 24) ECMO (n = 32) P-value NYHA, n (%)  I 2 (8) 3 (10) 0.03  II 1 (4) 9 (28)  III 4 (17) 9 (28)  IV 17 (71) 11 (34) CCS, n (%)  1 3 (13) 1 (3) 0.04  2 2 (8) 12 (38)  3 4 (16) 7 (21)  4 15 (63) 12 (38) EuroSCORE II, mean ± SD 28 ± 20 13 ± 16 0.01 Risk factors, n (%)  IABP 15 (63) 10 (31) 0.02  Dialysis 7 (30) 14 (44) 0.265  Multiorgan failure 3 (13) 8 (25) 0.319  Diabetes mellitus (insulin dependent) 2 (8) 1 (3) 0.571  Previous myocardial infarction 10 (42) 15 (47) 0.698  Previous CABG/angioplasty 13 (54) 5 (16) 0.002  Previous sternotomy 14 (58) 5 (16) 0.001  Right ventricular failure 6 (24) 4 (13) 0.429 Urgency of cardiac surgery, n (%) 0.065  Routine 6 (24) 18 (56)  Urgent 9 (38) 7 (22)  Emergency 9 (38) 7 (22) Type of cardiac surgery, n (%) 0.179  CABG 9 (38) 8 (25)  Valve 7 (30) 5 (16)  Aorta 3 (12) 2 (6)  Mixed 5 (20) 17 (53) VAD (n = 24) ECMO (n = 32) P-value NYHA, n (%)  I 2 (8) 3 (10) 0.03  II 1 (4) 9 (28)  III 4 (17) 9 (28)  IV 17 (71) 11 (34) CCS, n (%)  1 3 (13) 1 (3) 0.04  2 2 (8) 12 (38)  3 4 (16) 7 (21)  4 15 (63) 12 (38) EuroSCORE II, mean ± SD 28 ± 20 13 ± 16 0.01 Risk factors, n (%)  IABP 15 (63) 10 (31) 0.02  Dialysis 7 (30) 14 (44) 0.265  Multiorgan failure 3 (13) 8 (25) 0.319  Diabetes mellitus (insulin dependent) 2 (8) 1 (3) 0.571  Previous myocardial infarction 10 (42) 15 (47) 0.698  Previous CABG/angioplasty 13 (54) 5 (16) 0.002  Previous sternotomy 14 (58) 5 (16) 0.001  Right ventricular failure 6 (24) 4 (13) 0.429 Urgency of cardiac surgery, n (%) 0.065  Routine 6 (24) 18 (56)  Urgent 9 (38) 7 (22)  Emergency 9 (38) 7 (22) Type of cardiac surgery, n (%) 0.179  CABG 9 (38) 8 (25)  Valve 7 (30) 5 (16)  Aorta 3 (12) 2 (6)  Mixed 5 (20) 17 (53) CABG: coronary artery bypass grafting; CCS: Canadian Cardiovascular Society; ECMO: extracorporeal membrane oxygenation; IABP: intra-aortic balloon pump; NYHA: New York Heart Association; SD: standard deviation; VAD: ventricular assist device. Three patients in the VAD group and 6 patients in the ECMO group received mechanical circulatory assist after leaving the theatre following primary cardiac surgery. According to our institutional surgical strategies, while all patients from the VAD cohort underwent central cannulation, 72% of patients from the ECMO group were cannulated centrally, and the remaining patients underwent peripheral ECMO implantation through the groin vessels (P = 0.007). Eight patients with a dilated left ventricle on Day 1 of ECMO implantation received a left ventricular vent, which was connected to the outflow cannula of the ECMO circuit. Importantly, distal perfusion through the femoral artery was ensured in each case using either peripheral DPC or a sheath. In terms of implantation timing, no significant differences in the 2 groups were found with the mean implantation delay of 0.9 ± 1.4 vs 0.7 ± 1.2 h in the VAD group versus the ECMO group, respectively (P = 0.569). After implantation of MCS and initial stabilization, further haemodynamic parameters were assessed in each group on the first postoperative day (Table 3). Although most of the parameters did not show any statistical significance between the 2 groups, the incidence of early multiorgan failure (MOF) appeared to be statistically higher in the ECMO group (67% vs 26%, P = 0.009). Also ECMO patients had higher pO2 (P < 0.001) and lower ALP (P = 0.040) values. Table 3: Haemodynamic and laboratory parameters on Day 1 of mechanical circulatory assist VAD (n = 24) ECMO (n = 32) P-value ECMO flow (l/min), mean ± SD 4.59 ± 0.84 4.73 ± 0.78 0.559 ECMO flow (dl/kg), mean ± SD 5.9 ± 1.4 5.3 ± 1.7 0.293 Pump RPM, median (IQR) 3475 (3013–3875) 4100 (3700–4300) 0.001 IABP, n (%) 15 (62.5) 18 (50) 0.326 Mechanical ventilation, n (%) 24 (100) 32 (100) 1.000 Dialysis, n (%) 13 (54.1) 22 (68) 0.429 Multiorgan failure, n (%) 6 (23) 21 (67) 0.009 Heart rate (bpm), mean ± SD 93 ± 11 88 ± 21 0.332 Mean arterial pressure (mmHg), median (IQR) 70 (60–76) 72 (64–81) 0.226 Central venous pressure (mmHg), median (IQR) 14 (11–16) 13 (11–15) 0.428 pH, mean ± SD 7.28 ± 0.55 7.41 ± 0.05 0.300 Lactate (mmol/l), median (IQR) 3 (1–7) 2 (2–4) 0.961 pO2 (kPa), median (IQR) 12 (11–13) 19 (14–26) <0.001 Urea (mmol/l), median (IQR) 7.8 (5.5–11.7) 7.4 (5.4–11.5) 0.817 Creatinine (mmol/l), median (IQR) 95 (72–120) 140 (81–177) 0.02 Bilirubin (mmol/l), median (IQR) 48 (20–81) 39 (24–90) 0.882 ALP (IU/l), median (IQR) 96 (30–756) 45 (36–54) 0.04 ALT (IU/l), median (IQR) 55 (33–124) 68 (39–448) 0.533 WBC (cells × 109 /l), median (IQR) 12 (11–22) 12 (9–16) 0.306 CRP (mg/dl), median (IQR) 136 (55–211) 125 (94–218) 0.710 VAD (n = 24) ECMO (n = 32) P-value ECMO flow (l/min), mean ± SD 4.59 ± 0.84 4.73 ± 0.78 0.559 ECMO flow (dl/kg), mean ± SD 5.9 ± 1.4 5.3 ± 1.7 0.293 Pump RPM, median (IQR) 3475 (3013–3875) 4100 (3700–4300) 0.001 IABP, n (%) 15 (62.5) 18 (50) 0.326 Mechanical ventilation, n (%) 24 (100) 32 (100) 1.000 Dialysis, n (%) 13 (54.1) 22 (68) 0.429 Multiorgan failure, n (%) 6 (23) 21 (67) 0.009 Heart rate (bpm), mean ± SD 93 ± 11 88 ± 21 0.332 Mean arterial pressure (mmHg), median (IQR) 70 (60–76) 72 (64–81) 0.226 Central venous pressure (mmHg), median (IQR) 14 (11–16) 13 (11–15) 0.428 pH, mean ± SD 7.28 ± 0.55 7.41 ± 0.05 0.300 Lactate (mmol/l), median (IQR) 3 (1–7) 2 (2–4) 0.961 pO2 (kPa), median (IQR) 12 (11–13) 19 (14–26) <0.001 Urea (mmol/l), median (IQR) 7.8 (5.5–11.7) 7.4 (5.4–11.5) 0.817 Creatinine (mmol/l), median (IQR) 95 (72–120) 140 (81–177) 0.02 Bilirubin (mmol/l), median (IQR) 48 (20–81) 39 (24–90) 0.882 ALP (IU/l), median (IQR) 96 (30–756) 45 (36–54) 0.04 ALT (IU/l), median (IQR) 55 (33–124) 68 (39–448) 0.533 WBC (cells × 109 /l), median (IQR) 12 (11–22) 12 (9–16) 0.306 CRP (mg/dl), median (IQR) 136 (55–211) 125 (94–218) 0.710 CRP: C reactive protein; ECMO: extracorporeal membrane oxygenation; IABP: intra-aortic balloon pump; IQR: interquartile range; NYHA: New York Heart Association; SD: standard deviation; VAD: ventricular assist device; WBC: white blood count. Table 3: Haemodynamic and laboratory parameters on Day 1 of mechanical circulatory assist VAD (n = 24) ECMO (n = 32) P-value ECMO flow (l/min), mean ± SD 4.59 ± 0.84 4.73 ± 0.78 0.559 ECMO flow (dl/kg), mean ± SD 5.9 ± 1.4 5.3 ± 1.7 0.293 Pump RPM, median (IQR) 3475 (3013–3875) 4100 (3700–4300) 0.001 IABP, n (%) 15 (62.5) 18 (50) 0.326 Mechanical ventilation, n (%) 24 (100) 32 (100) 1.000 Dialysis, n (%) 13 (54.1) 22 (68) 0.429 Multiorgan failure, n (%) 6 (23) 21 (67) 0.009 Heart rate (bpm), mean ± SD 93 ± 11 88 ± 21 0.332 Mean arterial pressure (mmHg), median (IQR) 70 (60–76) 72 (64–81) 0.226 Central venous pressure (mmHg), median (IQR) 14 (11–16) 13 (11–15) 0.428 pH, mean ± SD 7.28 ± 0.55 7.41 ± 0.05 0.300 Lactate (mmol/l), median (IQR) 3 (1–7) 2 (2–4) 0.961 pO2 (kPa), median (IQR) 12 (11–13) 19 (14–26) <0.001 Urea (mmol/l), median (IQR) 7.8 (5.5–11.7) 7.4 (5.4–11.5) 0.817 Creatinine (mmol/l), median (IQR) 95 (72–120) 140 (81–177) 0.02 Bilirubin (mmol/l), median (IQR) 48 (20–81) 39 (24–90) 0.882 ALP (IU/l), median (IQR) 96 (30–756) 45 (36–54) 0.04 ALT (IU/l), median (IQR) 55 (33–124) 68 (39–448) 0.533 WBC (cells × 109 /l), median (IQR) 12 (11–22) 12 (9–16) 0.306 CRP (mg/dl), median (IQR) 136 (55–211) 125 (94–218) 0.710 VAD (n = 24) ECMO (n = 32) P-value ECMO flow (l/min), mean ± SD 4.59 ± 0.84 4.73 ± 0.78 0.559 ECMO flow (dl/kg), mean ± SD 5.9 ± 1.4 5.3 ± 1.7 0.293 Pump RPM, median (IQR) 3475 (3013–3875) 4100 (3700–4300) 0.001 IABP, n (%) 15 (62.5) 18 (50) 0.326 Mechanical ventilation, n (%) 24 (100) 32 (100) 1.000 Dialysis, n (%) 13 (54.1) 22 (68) 0.429 Multiorgan failure, n (%) 6 (23) 21 (67) 0.009 Heart rate (bpm), mean ± SD 93 ± 11 88 ± 21 0.332 Mean arterial pressure (mmHg), median (IQR) 70 (60–76) 72 (64–81) 0.226 Central venous pressure (mmHg), median (IQR) 14 (11–16) 13 (11–15) 0.428 pH, mean ± SD 7.28 ± 0.55 7.41 ± 0.05 0.300 Lactate (mmol/l), median (IQR) 3 (1–7) 2 (2–4) 0.961 pO2 (kPa), median (IQR) 12 (11–13) 19 (14–26) <0.001 Urea (mmol/l), median (IQR) 7.8 (5.5–11.7) 7.4 (5.4–11.5) 0.817 Creatinine (mmol/l), median (IQR) 95 (72–120) 140 (81–177) 0.02 Bilirubin (mmol/l), median (IQR) 48 (20–81) 39 (24–90) 0.882 ALP (IU/l), median (IQR) 96 (30–756) 45 (36–54) 0.04 ALT (IU/l), median (IQR) 55 (33–124) 68 (39–448) 0.533 WBC (cells × 109 /l), median (IQR) 12 (11–22) 12 (9–16) 0.306 CRP (mg/dl), median (IQR) 136 (55–211) 125 (94–218) 0.710 CRP: C reactive protein; ECMO: extracorporeal membrane oxygenation; IABP: intra-aortic balloon pump; IQR: interquartile range; NYHA: New York Heart Association; SD: standard deviation; VAD: ventricular assist device; WBC: white blood count. Outcomes and complications are given in Table 4. Patients from the ECMO group had more blood transfusions (P = 0.001) and transfusions of platelets (P < 0.001), which however, was not associated with higher incidence of bleeding (P = 0.542), pericardial tamponade (P = 0.100) or re-exploration (P = 0.117). Despite successful implantation of DPC in all peripheral ECMO cases, 5 patients (16%) showed signs of limb ischaemia. Systemic inflammatory response syndrome (P < 0.001) and septic shock (P = 0.016) were more often noted in patients from the ECMO group. Re-exploration was required in 5 (21%) and 13 (41%) patients in the VAD and ECMO group, respectively. Most of the patients required re-exploration within 24 h of implantation of mechanical circulatory assist, and uncontrolled bleeding and temponade remained the principal causes for re-exploration. Re-exploration was not associated with acute kidney injury. A significantly higher proportion of patients was successfully weaned/upgraded in the VAD group [13 (54%) vs 4 (13%), P = 0.048] with a trend towards higher discharge rate [9 (38%) vs 5 (16%), P = 0.061]. Overall cumulative survival in early postoperative follow-up [Breslow (Generalized Wilcoxon) P = 0.017] and long-term follow-up [Log-rank (Mantel-Cox) P = 0.015] was significantly better in the VAD group (Fig. 1) accounting for 50% vs 18.8% at 30 days, 41.7% vs 18.8% at 6 months, 37.5% vs 15.6% at 1 year and 37.5% vs 15.6% at 4 years. Table 4: Outcomes VAD (n = 24) ECMO (n = 32) P-value Duration of support (days), median (IQR) 10 (4–23) 7 (4–10) 0.116 Awake, n (%) 9 (38) 1 (3) 0.001 Awake duration (days), median (IQR) 17 (4–21) 7 (7–7) 0.857 ITU stay (days), median (IQR) 12 (4–30) 8 (3–20) 0.262 Hospital stay (days), median (IQR) 24 (4–67) 8 (3–20) 0.193 Successful weaning/ upgrade, n (%) 13 (54) 9 (28) 0.04 Conversion to other MCS, n (%) 3 (13) 4 (13) 1.000 Discharge from hospital, n (%) 9 (38) 5 (16) 0.06 Blood and blood products (units) RBC, median (IQR) 10 (5–19) 28 (16–39) 0.001 Platelets, median (IQR) 2 (1–4) 9 (4–12) <0.001 FFP, mean ± SD 7.6 ± 7.2 9.3 ± 6.9 0.433 Cryoprecipitate, median (IQR) 0 (0–2) 0 (0–3) 0.989 Complications, n (%)  Culture positive infection 5 (21) 9 (28) 0.533  Septic shock 1 (4) 9 (28) 0.01  SIRS 1 (4) 16 (50) <0.001  Bleeding 16 (67) 23 (74) 0.542  Re-exploration 5 (21) 13 (41) 0.117  Tamponade 3 (13) 10 (31) 0.100  Limb ischaemia 0 5 (16) 0.06  Stroke 1 (4) 1 (3) 1.000  Hepatic failure 12 (50) 15 (47) 0.817  Renal failure 12 (50) 22 (69) 0.155 VAD (n = 24) ECMO (n = 32) P-value Duration of support (days), median (IQR) 10 (4–23) 7 (4–10) 0.116 Awake, n (%) 9 (38) 1 (3) 0.001 Awake duration (days), median (IQR) 17 (4–21) 7 (7–7) 0.857 ITU stay (days), median (IQR) 12 (4–30) 8 (3–20) 0.262 Hospital stay (days), median (IQR) 24 (4–67) 8 (3–20) 0.193 Successful weaning/ upgrade, n (%) 13 (54) 9 (28) 0.04 Conversion to other MCS, n (%) 3 (13) 4 (13) 1.000 Discharge from hospital, n (%) 9 (38) 5 (16) 0.06 Blood and blood products (units) RBC, median (IQR) 10 (5–19) 28 (16–39) 0.001 Platelets, median (IQR) 2 (1–4) 9 (4–12) <0.001 FFP, mean ± SD 7.6 ± 7.2 9.3 ± 6.9 0.433 Cryoprecipitate, median (IQR) 0 (0–2) 0 (0–3) 0.989 Complications, n (%)  Culture positive infection 5 (21) 9 (28) 0.533  Septic shock 1 (4) 9 (28) 0.01  SIRS 1 (4) 16 (50) <0.001  Bleeding 16 (67) 23 (74) 0.542  Re-exploration 5 (21) 13 (41) 0.117  Tamponade 3 (13) 10 (31) 0.100  Limb ischaemia 0 5 (16) 0.06  Stroke 1 (4) 1 (3) 1.000  Hepatic failure 12 (50) 15 (47) 0.817  Renal failure 12 (50) 22 (69) 0.155 ECMO: extracorporeal membrane oxygenation; FFP: fresh frozen plasma; IQR: interquartile range; MCS: mechanical circulatory support; RBC: red blood count; SD: standard deviation; SIRS: systemic inflammatory response syndrome; VAD: ventricular assist device. Table 4: Outcomes VAD (n = 24) ECMO (n = 32) P-value Duration of support (days), median (IQR) 10 (4–23) 7 (4–10) 0.116 Awake, n (%) 9 (38) 1 (3) 0.001 Awake duration (days), median (IQR) 17 (4–21) 7 (7–7) 0.857 ITU stay (days), median (IQR) 12 (4–30) 8 (3–20) 0.262 Hospital stay (days), median (IQR) 24 (4–67) 8 (3–20) 0.193 Successful weaning/ upgrade, n (%) 13 (54) 9 (28) 0.04 Conversion to other MCS, n (%) 3 (13) 4 (13) 1.000 Discharge from hospital, n (%) 9 (38) 5 (16) 0.06 Blood and blood products (units) RBC, median (IQR) 10 (5–19) 28 (16–39) 0.001 Platelets, median (IQR) 2 (1–4) 9 (4–12) <0.001 FFP, mean ± SD 7.6 ± 7.2 9.3 ± 6.9 0.433 Cryoprecipitate, median (IQR) 0 (0–2) 0 (0–3) 0.989 Complications, n (%)  Culture positive infection 5 (21) 9 (28) 0.533  Septic shock 1 (4) 9 (28) 0.01  SIRS 1 (4) 16 (50) <0.001  Bleeding 16 (67) 23 (74) 0.542  Re-exploration 5 (21) 13 (41) 0.117  Tamponade 3 (13) 10 (31) 0.100  Limb ischaemia 0 5 (16) 0.06  Stroke 1 (4) 1 (3) 1.000  Hepatic failure 12 (50) 15 (47) 0.817  Renal failure 12 (50) 22 (69) 0.155 VAD (n = 24) ECMO (n = 32) P-value Duration of support (days), median (IQR) 10 (4–23) 7 (4–10) 0.116 Awake, n (%) 9 (38) 1 (3) 0.001 Awake duration (days), median (IQR) 17 (4–21) 7 (7–7) 0.857 ITU stay (days), median (IQR) 12 (4–30) 8 (3–20) 0.262 Hospital stay (days), median (IQR) 24 (4–67) 8 (3–20) 0.193 Successful weaning/ upgrade, n (%) 13 (54) 9 (28) 0.04 Conversion to other MCS, n (%) 3 (13) 4 (13) 1.000 Discharge from hospital, n (%) 9 (38) 5 (16) 0.06 Blood and blood products (units) RBC, median (IQR) 10 (5–19) 28 (16–39) 0.001 Platelets, median (IQR) 2 (1–4) 9 (4–12) <0.001 FFP, mean ± SD 7.6 ± 7.2 9.3 ± 6.9 0.433 Cryoprecipitate, median (IQR) 0 (0–2) 0 (0–3) 0.989 Complications, n (%)  Culture positive infection 5 (21) 9 (28) 0.533  Septic shock 1 (4) 9 (28) 0.01  SIRS 1 (4) 16 (50) <0.001  Bleeding 16 (67) 23 (74) 0.542  Re-exploration 5 (21) 13 (41) 0.117  Tamponade 3 (13) 10 (31) 0.100  Limb ischaemia 0 5 (16) 0.06  Stroke 1 (4) 1 (3) 1.000  Hepatic failure 12 (50) 15 (47) 0.817  Renal failure 12 (50) 22 (69) 0.155 ECMO: extracorporeal membrane oxygenation; FFP: fresh frozen plasma; IQR: interquartile range; MCS: mechanical circulatory support; RBC: red blood count; SD: standard deviation; SIRS: systemic inflammatory response syndrome; VAD: ventricular assist device. Figure 1: View largeDownload slide The Kaplan–Meier survival curve. Overall cumulative survival in early postoperative follow-up [Breslow (Generalized Wilcoxon) P = 0.017] and long-term follow-up [Log-rank (Mantel-Cox) P = 0.015] was significantly better in the VAD group. ECMO: extracorporeal membrane oxygenation; VAD: ventricular assist device. Figure 1: View largeDownload slide The Kaplan–Meier survival curve. Overall cumulative survival in early postoperative follow-up [Breslow (Generalized Wilcoxon) P = 0.017] and long-term follow-up [Log-rank (Mantel-Cox) P = 0.015] was significantly better in the VAD group. ECMO: extracorporeal membrane oxygenation; VAD: ventricular assist device. DISCUSSION Increasing age, prolonged CPB time, acute myocardial infarction, presence of shock, coagulation disorders and a variable degree of right heart failure in PCCS have been implicated in the early development of MOF and poor survival [5]. However, survival in patients requiring VAD for PCCS has improved over time with rapid strides in technology and critical care. Two larger studies using short-term VAD for PCCS, published 14 years apart, show an increase in survival from 25% to 54% [5, 7]. A larger series viewing ECMO trends in the USA concludes that although overall ECMO use had increased between 2002 and 2012, the proportion of ECMO used for PCCS had decreased from 56.9% to 37.9%. Also, mortality in PCCS remained high at 60% with no significant change during this period [8]. Several other studies regarding the use of ECMO for PCCS demonstrated in-hospital mortality rates between 59% and 76% without substantial improvement despite advances in ECMO technology [9–11]. Two recent studies comparing VAD and ECMO in patients with cardiogenic shock not specific to PCCS demonstrated equivalent outcomes in terms of survival and complications [12, 13]. In the present study, we compared VAD and ECMO used in the management of PCCS and found that the group of patients treated with VAD had significantly better survival rates compared to that of ECMO. An assist device that provides longer duration of circulatory support with minimum complications is essential in PCCS, as myocardial recovery time is unpredictable. As patients spend more time on the MCS, the chances of complications related to anticoagulation (bleeding and thromboembolism), sepsis and pump failure increase exponentially. In a series with PCCS supported on ECMO and VAD, the increased duration of support was associated with poor outcome; only 20% patients with support more than 4 days could survive discharge to home [14]. The duration of support that ECMO can provide is limited due to its inherent tendency for bleeding and other complications. Low incidence of device-related complications is essential for successful weaning from MCS, discharge from hospital and a good survival rate. VAD, due to the absence of oxygenator, requires a less stringent anticoagulation strategy compared to the ECMO and therefore may have lesser complications related to bleeding [15]. In the present study, the patients on ECMO required a significantly higher number of blood and platelet transfusions, however, not associated with higher rate of tamponade and re-exploration for bleeding. ECMO can be implanted peripherally via groin vessels—this avoids chest reopening as in VAD; however, it is vulnerable to complications, such as limb ischaemia. In the present study, 16% of all ECMO patients suffered limb ischaemia; of these patients, some required intervention despite utilizing specialized cannulas for distal limb perfusion [6]. This can be explained that DPC may bend or thrombose during support as shown in our previous study [6]. On the other hand, ECMO in patients with PCCS is associated with other advantages, such as simplicity of peripheral cannulation leading to a more rapid achievement of support, the possibility of chest closure in cases of peripheral implantation potentially lowering the incidence of mediastinitis and wound infections, and lower invasiveness in central cannulation in cases of biventricular failure (only 2 cannulas utilizing ECMO compared to 4 cannulas using BIVAD). Unlike VAD, ECMO increases systemic flow and pressure without directly unloading the left side of the heart. As a result, the failing LV might not have sufficient contractility to open the aortic valve. This causes progressive LV distention, which impairs myocardial recovery and can lead to pulmonary oedema, pulmonary haemorrhage and LV thrombus formation [16, 17]. This may require the introduction of an additional cannula into the left atrium via sternotomy or thoracotomy to off-load the left atrium [18]. As this additional LV cannula was not applied in our centre as a standard procedure, this might be one of the factors leading to poorer results in the ECMO group in the present study. VAD, on the other hand, offloads the left side of the heart efficiently, potentially avoiding pulmonary oedema and LV distension and hastens myocardial recovery. However, it proves less effective in associated right ventricular failure, requiring RVAD implantation. LVAD with inflow cannula in the left atrium with full flow and very poor LV may lead to the development of LV thrombus. Insertion of the inflow cannula into the LV apex is recommended in such cases. MCS can also be initiated in awake patients, or patients can be awakened on MCS. The ‘awake MCS strategy’ may avoid complications related to mechanical ventilation, sedation and immobilization. In our previous study, we have demonstrated significantly superior outcomes in patients with cardiogenic shock treated with MCS and kept awake compared to the non-awake control group [19]. In the present study, 38% of patients in the VAD group were awake compared to 3% of patients in the ECMO group. The key benefit of maintaining patients in the wake state on MCS therapy is the avoidance of complications associated with general anaesthesia/sedation, intubation and mechanical ventilation. Early mobilization of patients allows them to participate in active physiotherapy as well as helps in improving nutritional status. ECMO, due to the complexity of its circuit, is not favoured for mobilization; additionally, the ones implanted via groin vessels further restrict mobilization. ECMO is endowed with an oxygenator, which is a potential advantage over VAD, especially in a situation of poor gas exchange. Pre-existing poor lung function, prolonged CPB, multiple blood and blood products transfusions, fluid overload, pulmonary oedema due to inadequate mitral valve repair or poor LV function are common in PCCS. ECMO is preferred over VAD in such scenarios as it provides circulatory as well as respiratory support. However, VAD implanted in such situations may offload the left side of the heart, improve gas exchange by reducing pulmonary oedema and thus potentially avoid the need for an oxygenator. Nevertheless, VAD therapy can be escalated as and when required. Right ventricular failure occurs in 20–40% of implantable LVAD recipients, and RVAD support is required in ∼5% of the cases [20]. RVAD support may be required after LVAD implantation immediately or subsequently during LVAD therapy and mandates chest reopening for its implantation. In case of poor gas exchange, in patients with LVAD or BIVAD, we have already shown that an oxygenator can be introduced in the LVAD or RVAD circuit at the bedside without additional surgery [21, 22]. ECMO, by bypassing heart and lung and providing circulatory and respiratory support, offers blanket treatment for left ventricular failure, biventricular failure and lung failure. PCCS has a broad spectrum for its severity, and right ventricular failure and lung failure are at the extreme end of its spectrum. VAD is a versatile MCS which can be readily converted into BIVAD and has room for the introduction of an oxygenator into its circuit. The management of PCCS requiring MCS should begin with LVAD, and it could be sufficient for patients with left ventricular failure, less severe right ventricular failure and pulmonary oedema. In case of severe right ventricular failure leading to inadequate flow in LVAD with optimum filling and inotropic support, the RVAD can be implanted. In case of persistent poor gas exchange despite optimum LVAD flow and low filling pressures, the oxygenator may be introduced into the LVAD or RVAD circuit. This not only avoids ECMO, related complications and bypassing of the heart and lung but also offers phased weaning of MCS along with the restoration of lung and heart function, usually the oxygenator, followed by RVAD and LVAD explantation. Limitations This study is an analysis of prospectively collected registry data. As this was a non-blinded study of MCS at a single medical centre, we cannot exclude bias and confounding factors in terms of patient selection and their treatment. As with most single-centre MCS analyses, the power of the study was limited. The study cohort was small. Several variables in baseline characteristics and outcomes did not reach statistical significance due to the small cohort. The choice of VAD versus ECMO implantation in the setting of biventricular failure particularly in cases without respiratory failure was based on the surgeon’s preference and experience. This confounding factor cannot be excluded due to the retrospective design and the small patient cohort. Also, isolated LVAD or RVAD was included, each carrying specific indications that may not necessitate the use of full ECMO. CONCLUSIONS To the best of our knowledge, this study is the first analysis comparing the VAD and ECMO therapies in the management of PCCS to date. Both short-term VAD and ECMO represent essential tools to support patients with PCCS. Our preliminary results might indicate some benefits of using VAD in selected high-risk patients; however, this evidence should be further assessed in larger multicentre trials. ACKNOWLEDGEMENTS Smita Mohite and Nutan Patil helped in the analysis and interpretation of data. Conflict of interest: none declared. 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TI - Comparison of temporary ventricular assist devices and extracorporeal life support in post-cardiotomy cardiogenic shock
JO - Interactive CardioVascular and Thoracic Surgery
DO - 10.1093/icvts/ivy185
DA - 2018-06-13
UR - https://www.deepdyve.com/lp/oxford-university-press/comparison-of-temporary-ventricular-assist-devices-and-extracorporeal-MZKheHPNlS
SP - 1
VL - Advance Article
IS - 
DP - DeepDyve
ER -