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Extracorporeal Membrane Oxygenation in New York State: Trends, Outcomes, and Implications for Patient Selection
Jaya Batra1, Nana Toyoda1, Andrew B Goldstone1
1From the Department of Cardiovascular Surgery (J.B., N.T., S.I., J.C.) and Department of Population Health Science and Policy (N.N.E.), Icahn School of Medicine at Mount Sinai, New York, NY; and Department of Cardiothoracic Surgery, Stanford University School of Medicine, CA (A.B.G.).
Background:
Utilization of extracorporeal membrane oxygenation (ECMO) is expanding despite limited outcome data defining appropriate use.
Methods And Results:
To quantify determinants of early and 1-year survival after ECMO in adult patients, we conducted a retrospective cohort analysis of 1286 patients aged ≥18 years who underwent ECMO in New York State from 2003 to 2014. Median follow-up time was 4.9 months (range, 0-12 months). ECMO utilization increased from 13 patients in 8 hospitals in 2003 to 330 patients in 30 hospitals in 2014. Compared with patients undergoing ECMO before 2009, later patients were older (54.4 versus 52.3 years; P=0.013) and more likely to have major comorbidity including chronic kidney disease (25.2% versus 13.2%; P=0.02) and liver disease (20.0% versus 10.7%; P=0.001). In the overall cohort, 30-day mortality was 52.2% (95% confidence interval, 49.5-54.9). Mortality at 30 days was 65.2% for patients aged ≥75 years (n=73/112) and 74.6% in patients who required cardiopulmonary resuscitation (n=91/122). Survival at 1 year was 38.4% (95% confidence interval, 35.7-41.0). The 30-day mortality and 1-year survival improved across the study period. In multivariable analysis, earlier year of ECMO, lower hospital volume, indication for ECMO after a cardiac procedure, cardiopulmonary resuscitation before ECMO placement, and age >65 years were independent predictors of worse survival.
Conclusions:
Outcomes of ECMO have improved despite increasing comorbidity. Extreme mortality after ECMO in elderly patients and patients requiring cardiopulmonary resuscitation indicates that less invasive therapeutic or palliative modalities may be more appropriate in this end-of-life setting.
