Original Investigation
Left Ventricular Unloading During Extracorporeal Membrane Oxygenation in Patients With Cardiogenic Shock

https://doi.org/10.1016/j.jacc.2018.10.085Get rights and content
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Abstract

Background

Venoarterial extracorporeal membrane oxygenation (VA-ECMO) is a widely used form of mechanical circulatory support in patients with refractory cardiogenic shock. A common drawback of this modality is a resultant increase in left ventricular afterload.

Objectives

The purpose of this meta-analysis was to examine the efficacy and safety of left ventricular unloading strategies during VA-ECMO in adult patients with cardiogenic shock.

Methods

The authors performed a systematic search of studies examining left ventricular unloading during VA-ECMO in Medline, EMBASE, and the Cochrane library. The primary outcome was all-cause mortality. Secondary outcomes included limb ischemia, bleeding, need for renal replacement therapy, multiorgan failure, stroke or transient ischemic attack, and hemolysis.

Results

Of 2,221 publications identified, 17 observational studies met the inclusion criteria. In total, outcomes in 3,997 patients were included with 1,696 (42%) receiving a concomitant left ventricular unloading strategy while on VA-ECMO (intra-aortic balloon pump 91.7%, percutaneous ventricular assist device 5.5%, pulmonary vein or transseptal left atrial cannulation 2.8%). There were 2,412 deaths (60%) in the total cohort. Mortality was lower in patients with (54%) versus without (65%) left ventricular unloading while on VA-ECMO (risk ratio: 0.79; 95% confidence interval: 0.72 to 0.87; p < 0.00001). Hemolysis was higher in patients who underwent VA-ECMO with left ventricular unloading. Otherwise, secondary outcomes were not demonstrably different in patients treated with VA-ECMO with versus without left ventricular unloading.

Conclusions

In observational studies, left ventricular unloading was associated with decreased mortality in adult patients with cardiogenic shock treated with VA-ECMO. In the absence of prospective randomized data, left ventricular unloading may be considered for appropriately selected patients undergoing VA-ECMO support.

Key Words

cardiogenic shock
extracorporeal membrane oxygenation
resuscitation

Abbreviations and Acronyms

IABP
intra-aortic balloon pump
pVAD
percutaneous ventricular assist device
VA-ECMO
venoarterial extracorporeal membrane oxygenation

Cited by (0)

Dr. So has received research grant support from Eli Lilly, Spartan Bioscience Inc., Roche Diagnostics, and Aggredyne; and has received consulting honoraria from AstraZeneca, Bayer, and Abiomed. Dr. Garan is supported by National Institute of Health Grant No. KL2TR001874; and has received honoraria from and served as an unpaid consultant for Abiomed. Dr. Karmpaliotis has received honoraria from Abbott Vascular and Boston Scientific. Dr. Kirtane’s institutions, Columbia University and Cardiovascular Research Foundation, have received funding from Medtronic, Boston Scientific, Abbott Vascular, Abiomed, CSI, CathWorks, Siemens, Philips, and/or ReCor Medical. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.

Listen to this manuscript's audio summary by Editor-in-Chief Dr. Valentin Fuster on JACC.org.

© 2019 The Authors. Published by Elsevier on behalf of the American College of Cardiology Foundation.