1. T RENDS IN U.S. E XTRACORPOREAL M EMBRANE O XYGENATION U TILIZATION AND O UTCOMES : 2002-2012 Fenton H McCarthy, Katherine M McDermott, Ashley Hoedt, Vinay Kini, Jacob T Gutsche, Joyce W Wald, Dawei Xie, Wilson Y Szeto, Michael Acker, Nimesh D Desai Division of Cardiovascular Surgery University of Pennsylvania 95 th AATS Annual Meeting April 2015, Seattle WA

2. D ISCLOSURES None

3. B ACKGROUND — ECMO U TILIZATION Extracorporeal Life Support Organization (ELSO) and their associated registry Paden et al ASAIO 2013. Adult Cardiac ECMO Adult Respiratory ECMO

4. Previous studies demonstrated progressively increased ECMO cost Maxwell et al. JTCVS 2014 p < 0.01 Millions of Dollars B ACKGROUND — ECMO C OST

5. Q UESTIONS R EMAIN R EGARDING C URRENT ECMO U SE IN A DULTS 1.Trajectory of ECMO use across the country 2.Perceived shifts in the primary indication for ECMO use

6. O BJECTIVE Evaluate contemporary national trends in volume, outcomes, and clinical presentation of adult patients in the NIS database undergoing ECMO.

7. NIS D ATA AND ECMO P ATIENTS National Inpatient Sample (NIS) excellent source to evaluated ECMO outcomes Largest publicly available all payer database 2012: 7-8M admissions, 1000 hospitals, 44 states – 20% stratified sample – Includes weights to facilitate national estimates Size permits study of rare conditions/events

8. NIS discharges from 2002-2012 of adult patients undergoing ECMO – Identified using ICD-9 procedural codes – 39.65 (extracorporeal membrane oxygenation) – 39.66 (percutaneous extracorporeal membrane oxygenation) Discharge weights within NIS sampling frame used to estimate ECMO hospitalizations (n=12,157) M ETHODS

9. Six mutually-exclusive groups by ECMO indication: 1.Post-cardiotomy 2.Heart transplant 3.Lung transplant 4.Cardiogenic shock 5.Respiratory failure 6.Cardiopulmonary failure M ETHODS

10. Primary outcome was survival as discharge – Entire adult population – Primary indication for ECMO A Mann–Kendall test was used to examine trends over time Means and frequencies were calculated using SAS software statistical techniques for survey data M ETHODS

11. R ESULTS — ECMO U TILIZATION AND M ORTALITY 2002-2012

12. C HARACTERISTICS AND O UTCOMES OF ECMO A DMISSIONS BY E RA All (n=12,157) 2002-2006 (n=2,639) 2007-2012 (n=9,519)p Male (%)6257620.03 White (%)6876660.01 Age (mean, 95% CI)51.9 (51.0 - 52.8)53.5 (51.3 - 55.6)51.4 (50.5 - 52.4)0.05 Elective Admission (%)284024<0.01 Hospital Type Rural (%)1210.14 Uban, non-teaching (%)91380.07 Urban, teaching (%)9085910.03 Mortality5652580.12 Length of stay (days)20.6 (18.8 - 22.4)17.5 (14.6 - 20.4)21.5 (14.3 - 18.2)0.04 ECMO Insertion to Discharge (days) 15.7 (13.9 - 17.4)13.4 (10.9 - 15.8)16.2 (14.3 - 18.2) 0.17

13. C HARACTERISTICS AND O UTCOMES OF ECMO A DMISSIONS BY E RA All (n=12,157) 2002-2006 (n=2,639) 2007-2012 (n=9,519)p Male (%)6257620.03 White (%)6876660.01 Age (mean, 95% CI)51.9 (51.0 - 52.8)53.5 (51.3 - 55.6)51.4 (50.5 - 52.4)0.05 Elective Admission (%)284024<0.01 Hospital Type Rural (%)1210.14 Uban, non-teaching (%)91380.07 Urban, teaching (%)9085910.03 Mortality5652580.12 Length of stay (days)20.6 (18.8 - 22.4)17.5 (14.6 - 20.4)21.5 (14.3 - 18.2)0.04 ECMO Insertion to Discharge (days) 15.7 (13.9 - 17.4)13.4 (10.9 - 15.8)16.2 (14.3 - 18.2) 0.17 2007-2012: Fewer women, whites, elective admissions Younger patients More urban teaching admission, longer length of stays Similar survival

14. ECMO A DMISSIONS BY D IAGNOSTIC G ROUP

15. ECMO use in every diagnostic group increased significantly over the study period Significant changes in the case-mix included: – Decreased post-cardiotomy ECMO use from 56.9% of all in 2002 to 37.9% in 2012 (p=0.026) – Increased cardiopulmonary failure ECMO from 3.9% to 11.1% (p=0.026) R ESULTS

16. ECMO C LINICAL I NDICATION 2002 - 2012 2002 2012

17. ECMO I NDICATION AND U SE 2002 2012 Change in pie chart size proportional to increase in ECMO use in 2002 v 2012 (n = 352) (n = 2,715)

18. I N -H OSPITAL M ORTALITY B Y D IAGNOSTIC G ROUP MortalityMortality (95% CI)p Cardiogenic Shock0.59 (0.54 - 0.65)0.445 Post-Cardiotomy0.57 (0.52 - 0.62)0.026 (Decreasing) Cardiopulmonary Failure0.55 (0.48 - 0.63)0.026 (Increasing) Acute Respiratory Failure0.53 (0.48 - 0.58)0.542 Lung Transplant0.45 (0.35 - 0.56)0.218 Heart Transplant0.44 (0.35 - 0.53)0.391

19. From 2002-2012, national ECMO use increased significantly Increased use driven primarily by rising national ECMO utilization beginning in 2007. ECMO use increased for all indications but possibly recent changes case mix C ONCLUSIONS

20. Mortality rates remained high but stable during this time period Within indication groups, some modest changes in mortality were identifiable C ONCLUSIONS

21. Hospital of the University of Pennsylvania c.1891

22. I N -H OSPITAL M ORTALITY B Y D IAGNOSTIC G ROUP 2007-2012 2007 – 2012 Pairwise Comparisons IndicationN Mortality (95% CI) Cardiogenic Shock Post- Cardiotomy Cardiopulmonary Failure Acute Respiratory Failure Heart Transplant Lung Transplant Cardiogenic Shock22210.63 (0.57 - 0.69).0.48720.22390.03180.00420.0168 Post-Cardiotomy36260.60 (0.55 - 0.65)..0.47080.09960.01140.0369 Cardiopulmonary Failure 10120.56 (0.48 - 0.65)...0.62220.10.1539 Acute Respiratory Failure 16440.54 (0.48 - 0.60)....0.18550.2282 Heart Transplant3860.45 (0.34 - 0.55).....0.974 Lung Transplant6300.44 (0.31 - 0.58)...... pp=0.018