Authors' objectives: This report will focus primarily on use of VA-ECMO in adults, because that is the modality used by the majority of McGill University Health Centre (MUHC) cases, i.e. those with acute heart failure requiring cardiac support. The objectives of this report are to: 1. review the evidence on the outcomes, efficacy and safety of VA-ECMO 2. review the literature to identify optimal patient selection variables for VA-ECMO 3. review the literature to identify programmatic factors that promote optimal ECMO utilization, 4. summarize the MUHC experience with ECMO, focusing primarily on outcomes and cost

Authors' recommendations: ECMO is a temporary life support technique to support patients with acute heart or respiratory failure and high risk of mortality. Since 2010, ECMO use in adults has increased, and indications have expanded to adults in cardiac failure. • Given the limited evidence base, it remains unclear whether VA-ECMO prolongs survival and results in better neurological outcomes relative to alternative treatments such as ventricular assist devices, cardiopulmonary bypass and mechanical ventilation. Data from comparative studies suggest some evidence of improved survival with ECPR relative to conventional CPR. However, ongoing RCTs of ECPR vs conventional CPR in cardiac arrest patients indicate continued equipoise for trials of ECMO in this population. Data from case series indicate that survival to discharge after VA-ECMO for cardiogenic shock is approximately 40%. • Although some organizations have attempted to develop guidelines for indications of ECMO use, the current literature has not established clear normative guidelines due to the heterogeneous study population and limited body of evidence on clear indicators for survival. • Recent evidence suggests that patients receiving ECMO at high-volume centres (>30 adult ECMO cases per year) have lower mortality rates than those treated at centres with fewer than six adult cases annually, making the case for concentrating ECMO treatment in a few high-volume centres. • At the MUHC, 41 adults have been supported with ECMO since 2013. Survival was comparable to data reported in large case series (49% at weaning and 38% at 30 days). The estimated total cost of treating 20 patients with VA-ECMO is $361,211 assuming each patient spends 3 days on ECMO. The estimated budget impact (additional costs incurred by the use of ECMO) of treating a patient with VA-ECMO for 3 days is $13,289.35. • ECMO is a resource-intensive technology, and the recent rise in ECMO cases at the MUHC has placed an increased burden on limited resources, including perfusionist time. There is a need for dedicated funding to ease this burden and avoid unwanted delays in access to care.

Project Status: Completed

Year Published: 2017

URL for published report: http://www.mcgill.ca/tau/files/tau/muhc_tau_2017_ecmo_a_0.pdf

English language abstract: An English language summary is available

Publication Type: Not Assigned

Country: Canada

Organisation Name: Technology Assessment Unit of the McGill University Health Centre (MUHC)

Contact Address: Technology Assessment Unit of the MUHC, 536-5100 Boul. Maisonneuve O, Montreal, H4A 3T2

Contact Name: eva.suarthana@mcgill.ca

Contact Email: nisha.almeida@muhc.mcgill.ca

Copyright: Technology Assessment Unit of the McGill University Health Centre (MUHC)