2020 EACTS/ELSO/STS/AATS Expert Consensus on Post-Cardiotomy Extracorporeal Life Support in Adult Patients Roberto Lorusso, MD, PhD, Chairperson,* Glenn Whitman, MD, Chairperson,* Milan Milojevic, MD, PhD,* Giuseppe Raffa, MD, PhD, David M. McMullan, MD, Udo Boeken, MD, PhD, Jonathan Haft, MD, Christian A. Bermudez, MD, Ashish S. Shah, MD, and David A. D’Alessandro, MD Department of Cardio-Thoracic Surgery, Heart & Vascular Center, Maastricht University Medical Center, Cardiovascular Research Institute Maastricht, Maastricht, Netherlands; Cardiac Intensive Care Unit, Johns Hopkins Hospital, Baltimore, Maryland; Department of Anesthesiology and Critical Care Medicine, Dedinje Cardiovascular Institute, Belgrade, Serbia; Department of Cardiovascular Research, Dedinje Cardiovascular Institute, Belgrade, Serbia; Department of Cardiothoracic Surgery, Erasmus University Medical Center, Rotterdam, Netherlands; Department for the Treatment and Study of Cardiothoracic Diseases and Cardiothoracic Transplantation, IRCCS- ISMETT (Istituto Mediterraneo per i Trapianti e Terapie ad Alta Specializzazione), Palermo, Italy; Department of Cardiac Surgery, Seattle Children Hospital, Seattle, Washington; Department of Cardiac Surgery, Heinrich Heine University, Dusseldorf, Germany; Section of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan; Department of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania; Department of Cardio-Thoracic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee; and Department of Cardio-Thoracic Surgery, Massachusetts General Hospital, Boston, Massachusetts Post-cardiotomy extracorporeal life support (PC-ECLS) in might be of use for the practitioner, and possibly adult patients has been used only rarely but recent data improve patient management in this setting, the authors have shown a remarkable increase in its use, almost have attempted to create a concise, comprehensive and certainly due to improved technology, ease of manage- relevant analysis of all aspects related to PC-ECLS, with a ment, growing familiarity with its capability and particular emphasis on indications, technique, manage- decreased costs. Trends in worldwide in-hospital survival, ment and avoidance of complications, appraisal of new however, rather than improving, have shown a decline in approaches and ethics, education and training. some experiences, likely due to increased use in more complex, critically ill patients rather than to suboptimal (Ann Thorac Surg 2021;111:327-69) management. Nevertheless, PC-ECLS is proving to be a Ó 2021 Jointly between The Society of Thoracic Surgeons, valuable resource for temporary cardiocirculatory and the American Association for Thoracic Surgery, respiratory support in patients who would otherwise most the European Association for Cardio-Thoracic Surgery, likely die. Because a comprehensive review of PC-ECLS and the Extracorporeal Life Support Organization REPORT *Drs Lorusso, Whitman, and Milojevic contributed equally to this work. The Society of Thoracic Surgeons, the European Association for Cardio- Thoracic Surgery, the American Association for Thoracic Surgery, and the Extracorporeal Life Support Organization approved this document. 1. Preamble EACTS/ELSO/STS/AATS Committee Reviewers: Rakesh Christopher This document represents a joint effort by the European Arora (Canada), Nick Freemantle (UK), Christoph Knosalla (Germany), Association for Cardio-Thoracic Surgery (EACTS), Graeme Maclaren (Singapore), Evgenij V. Potapov (Germany), Christoph Schmid (Germany), Kiran Shekar (Australia), Scott Silvestri (USA), and Alexander Wahba (Norway). This article has been copublished in The Annals of Thoracic Surgery, The Dr Lorusso discloses a financial relationship with Journal of Thoracic and Cardiovascular Surgery, the European Journal of LivaNova, Medtronic, Eurosets, and PulseCath. All Cardio-Thoracic Surgery, and the ASAIO Journal. honoraria go to the university as research funds. The Society of Thoracic Surgeons requests that this article be cited as: Lorusso R, Whitman G, Milojevic M, et al. 2020 EACTS/ELSO/STS/AATS Expert Consensus on Post-Cardiotomy Extracorporeal Life Support in Adult Patients. Ann Thorac Surg. 2021;111:327–369. The Supplemental Tables and Supplemental Figure can be viewed in the online version of this article Address correspondence to Prof Dr Lorusso, Department of Cardio- Thoracic Surgery, Heart & Vascular Center, Maastricht University Med- [https://doi.org/10.1016/j.athoracsur.2020.07.009]on ical Center, Cardiovascular Research Institute Maastricht, Maastricht, https://www.annalsthoracicsurgery.org/. Netherlands; email: [email protected]. Ó 2021 Jointly between The Society of Thoracic Surgeons, the American Association for Thoracic Surgery, the European Association for Cardio-Thoracic Surgery, and the Extracorporeal Life Support Organization Ann Thorac Surg 2021;111:327-69 0003-4975/$36.00 Published by Elsevier Inc. https://doi.org/10.1016/j.athoracsur.2020.07.009 328 PRACTICE GUIDELINE LORUSSO ET AL Ann Thorac Surg PC-ECLS IN ADULT PATIENTS 2021;111:327-69 2. Methods Abbreviations and Acronyms Members of the 4 societies with significant experience in ACT = activated clotting time the field were selected and invited to join the task force by aPTT = activated partial thromboplastin their respective societies, which officially endorsed this time scientific and educational initiative. Following the meth- ARDS = acute respiratory distress syndrome odological quality assessment across available body of AT = antithrombin fi CABG = coronary artery bypass grafting evidence speci c recommendations were developed after fi CO = cardiac output careful consideration of the scienti c and medical CO2 = carbon dioxide knowledge contained in each article and the evidence CPB = cardiopulmonary bypass available at the time of its writing, following the methods DTIs = direct thrombin inhibitors manual for EACTS clinical guidelines.1 EACTS = European Association for Cardio- After the scope of the guidelines was agreed upon by Thoracic Surgery the task force members, the table of contents was estab- ECLS = extracorporeal life support lished, and topics were allocated to writing groups of at ECMO = extracorporeal membrane least 2 members during a face-to-face meeting. The oxygenation standardized Population, Intervention, Comparison, ECPR = extracorporeal cardiopulmonary resuscitation Outcome and Time (PICOT) framework was used to ELSO = Extracorporeal Life Support facilitate systematic literature review, establishing Organization answerable research questions. The systematic literature HIT = heparin-induced thrombocytopenia search was not restricted in terms of years but was mainly HTx = heart transplant focused on cardiac surgery in adults and did not include IABP = intra-aortic balloon pump studies in languages other than English. ICU = intensive care unit The systematic literature search was performed by the LCO = low cardiac output section authors and was also instrumental in identifying a LT-MCS = long-term mechanical circulatory recently published systematic review2 that received support further support from other recognized experts from the LV = left ventricle LVAD = left ventricular assist device worldwide ECLS community. An additional overall MCS = mechanical circulatory support complementary literature search was performed by a MI = myocardial infarction PhD fellow dedicated to the topic (G.R.) and member of Oxy-RVAD = right ventricular assist device with the task force. The medical evidence was critically oxygenator appraised for quality by a clinical epidemiologist (M.M.). PA = pulmonary artery All chapters were written through a close collaboration PC = post-cardiotomy between the task force members. Following the official PCS = post-cardiotomy shock policy for the EACTS clinical guidelines,1 the task force PGD = primary graft dysfunction members were asked to complete declarations of interest RCT = randomized controlled trial and write chapters only if they had no disclosures for the RRT = renal replacement therapy fi fi RV = right ventricle speci c topic. Agreement on the nalized document and RVAD = right ventricular assist device recommendations was reached through conference calls SAVE = Survival After Veno-arterial ECMO and face-to-face meetings, without excluding members ST-MCS = short-term mechanical circulatory with a conflict of interest. The hierarchy of evidence REPORT support required by the study design along with the internal hi- STS = The Society of Thoracic Surgeons erarchy based on the study quality was used to formulate V-A = veno-arterial levels and grades of recommendations. In the absence of V-V = veno-venous published evidence, expert consensus statements were made to cover specific issues that are essential to daily practice. The level of evidence and the strength of the the Extracorporeal Life Support Organization (ELSO), recommendations were weighed and graded according to fi the Society of Thoracic Surgeons (STS) and the American prede ned scales, as outlined in Tables 1 and 2. Association for Thoracic Surgery (AATS) to provide a position paper on post-cardiotomy extracorporeal life support (PC-ECLS) in adult patients, the goal of which is 3. Introduction and Terminology to provide comprehensive and useful recommendations PC-ECLS represents a well-established and valuable tool about the most relevant issues surrounding its applica- to rescue patients in refractory cardiocirculatory failure, tion and to