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LV unloading decreases mortality in VA-ECMO for cardiogenic shock
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Among patients with cardiogenic shock treated with venoarterial extracorporeal membrane oxygenation, or VA-ECMO, left ventricular unloading decreased the risk for mortality, according to a systematic review published in the Journal of the American College of Cardiology.
“Although limited by the caveats associated with interring causation from observational data, our analysis supports the use of left ventricular unloading in appropriately selected patients with refractory cardiogenic shock in whom VA-ECMO is used,” Juan J. Russo, MD, of the University of Ottawa Heart Institute in Ontario, Canada, and colleagues wrote.
Systematic review
Researchers analyzed data from 3,997 patients (mean age, 57 years; 29% women) from 17 observational studies that assessed the use of VA-ECMO for the treatment of patients with cardiogenic shock and had available data on mortality in those with and without an LV unloading strategy during VA-ECMO.
The primary outcome of interest was all-cause mortality.
Of the patients in the review, 42% underwent VA-ECMO. Intra-aortic balloon pumps were used in 91.7% of patients, 5.5% were treated with a percutaneous ventricular assist device and 2.8% of patients were treated with either a left atrial or pulmonary vein cannulation.
Mortality occurred in 60% of patients in the total cohort. The mortality rate was lower in patients with LV unloading while on VA-ECMO vs. those without it (54% vs. 65%; RR = 0.79; 95% CI, 0.72-0.87).
Secondary outcomes
More patients treated with LV unloading during VA-ECMO had hemolysis compared with those without unloading (RR = 2.15; 95% CI, 1.49-3.11).
Patients with and without VA-ECMO had similar rates of secondary outcomes, which included the rates of limb ischemia, bleeding, multiorgan failure, renal replacement therapy, and stroke or transient attack.
“The relative efficacy and safety of an upfront vs. bailout left ventricular unloading strategy is an important consideration for future study design,” Russo and colleagues wrote.
“Although we agree with this cautious recommendation, there remain several unanswered questions,” Vladimír Dzavík, BSc, MD, FRCPC, clinical researcher at Toronto General Hospital Research Institute, and Patrick R. Lawler, MD, MPH, clinician-scientist and assistant professor at Peter Munk Cardiac Centre at Toronto General Hospital, wrote in a related editorial. “First, who comprises these ‘selected’ patients? In most cases, the timing of unloading relative to VA-ECMO deployment was not reported. Likely, many patients were already on [intra-aortic balloon pump] or [percutaneous ventricular assist devices] support and underwent VA-ECMO deployment because of inadequate support from these devices. In these cases, unloading should be continued while the patient is on VA-ECMO. There appears to be no harm from the unloading strategy, at least based on observational data.” – by Darlene Dobkowski
Disclosures: Russo, Dzavík and Lawler report no relevant financial disclosures. Please see the study for all other authors’ relevant financial disclosures.
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