Postcardiotomy refers to the period immediately after open-heart surgery. Postcardiotomy cardiogenic shock (PCS) is a rare but life-threatening situation that happens when the efficiency of the heart as a pump is impaired and it is unable to meet the body's needs. This means a person may be unable to be separated from cardiopulmonary bypass after open-heart surgery. Persistent cardiogenic shock cannot be managed with medicines alone.
Treatment for PCS involves pharmacological treatments, including diuretics and inotropic agents, and mechanical circulatory support, including intra-aortic balloon pumps. Without using mechanical circulatory support, PCS has a very high risk of death, with mortality reported as high as 76%.
VA ECMO is used to provide cardiac and respiratory support for people with PCS. Unlike a heart–lung (cardiopulmonary) bypass machine, it tends to be used for days to weeks after surgery rather than for hours during surgery, allowing the heart time to recover. ECMO provides circulatory support and allows time for other treatments to promote recovery, or may be a bridge to a long-term mechanical solution or transplant. It aims to improve patient outcomes.
NICE did a rapid review of the published literature on the efficacy and safety of this procedure. This comprised a comprehensive literature search and detailed review of the evidence from 12 sources (13 publications), which was discussed by the committee. The evidence included 4 systematic reviews, 3 retrospective registry studies, 1 multicentre retrospective study and 4 single centre retrospective studies. It is presented in the summary of key evidence section in the interventional procedures overview. Other relevant literature is in the appendix of the overview.
The professional experts and the committee considered the key efficacy outcomes to be: restoration of organ function and bridging to recovery, transplant or long-term support.
The professional experts and the committee considered the key safety outcomes to be: bleeding, leg ischaemia, stroke, infection, renal failure and circuit-related complications.
Patient commentary was sought but none was received.
Clinical experts advised that some centres provide elective VA ECMO for people who are more likely to have PCS, and it is routinely used in some centres.
Clinical experts advised that VA ECMO can be done either peripherally or centrally. Central VA ECMO is used more commonly after cardiac surgery.
It would be difficult to do randomised controlled trials in people with PCS. So, other types of data collection such as registries could be useful.
The recommendations in this guidance include use of VA ECMO during pregnancy or in the postpartum period.
Clinical experts advised that this procedure could have a better outcome when it is used for post-transplant support because of primary graft dysfunction.
Some people who had VA ECMO have become organ donors and their organs have been transplanted.
The committee was told that starting VA ECMO to manage PCS as early as possible is very important for better outcomes.
The committee was told that a high level of nursing expertise and input from a perfusionist are needed to support people on VA ECMO.
Not all cardiac surgery centres specialise in using VA ECMO in the UK. So, people in some areas may not have access to this procedure.
Pregnancy and maternity are protected characteristics under the Equality Act (2010). Women, trans men and non-binary people with cardiogenic shock who are pregnant, or who have recently been pregnant, may need to access this intervention.