Left Ventricular Unloading Is Associated With Lower Mortality in Patients With Cardiogenic Shock Treated With Venoarterial Extracorporeal Membrane Oxygenation: Results From an International, Multicenter Cohort Study

• Published in: Circulation (New York, N.Y.) Vol. 142; no. 22; pp. 2095 - 2106
• Main Authors: Schrage, Benedikt, Becher, Peter Moritz, Bernhardt, Alexander, Bezerra, Hiram, Blankenberg, Stefan, Brunner, Stefan, Colson, Pascal, Cudemus Deseda, Gaston, Dabboura, Salim, Eckner, Dennis, Eden, Matthias, Eitel, Ingo, Frank, Derk, Frey, Norbert, Funamoto, Masaki, Goßling, Alina, Graf, Tobias, Hagl, Christian, Kirchhof, Paulus, Kupka, Danny, Landmesser, Ulf, Lipinski, Jerry, Lopes, Mathew, Majunke, Nicolas, Maniuc, Octavian, McGrath, Daniel, Möbius-Winkler, Sven, Morrow, David A, Mourad, Marc, Noel, Curt, Nordbeck, Peter, Orban, Martin, Pappalardo, Federico, Patel, Sandeep M, Pauschinger, Matthias, Pazzanese, Vittorio, Reichenspurner, Hermann, Sandri, Marcus, Schulze, P Christian, H.G. Schwinger, Robert, Sinning, Jan-Malte, Aksoy, Adem, Skurk, Carsten, Szczanowicz, Lukasz, Thiele, Holger, Tietz, Franziska, Varshney, Anubodh, Wechsler, Lukas, Westermann, Dirk
• Format: Journal Article
• Language: English
• Published: United States by the American College of Cardiology Foundation and the American Heart Association, Inc 01.12.2020; Lippincott Williams & Wilkins
• Subjects: Adult; Aged; Cohort Studies; Extracorporeal Membrane Oxygenation - mortality; Extracorporeal Membrane Oxygenation - trends; Female; Humans; Internationality; Male; Middle Aged; Mortality - trends; Original s; Shock, Cardiogenic - diagnosis; Shock, Cardiogenic - mortality; Shock, Cardiogenic - therapy; Treatment Outcome; Ventricular Function, Left - physiology; shock, cardiogenic; extracorporeal membrane oxygenation
• ISSN: 0009-7322; 1524-4539
• DOI: 10.1161/CIRCULATIONAHA.120.048792

BACKGROUND:Venoarterial extracorporeal membrane oxygenation (VA-ECMO) is increasingly used to treat cardiogenic shock. However, VA-ECMO might hamper myocardial recovery. The Impella unloads the left ventricle. This study aimed to evaluate whether left ventricular unloading in patients with cardiogenic shock treated with VA-ECMO was associated with lower mortality. METHODS:Data from 686 consecutive patients with cardiogenic shock treated with VA-ECMO with or without left ventricular unloading using an Impella at 16 tertiary care centers in 4 countries were collected. The association between left ventricular unloading and 30-day mortality was assessed by Cox regression models in a 1:1 propensity score–matched cohort. RESULTS:Left ventricular unloading was used in 337 of the 686 patients (49%). After matching, 255 patients with left ventricular unloading were compared with 255 patients without left ventricular unloading. In the matched cohort, left ventricular unloading was associated with lower 30-day mortality (hazard ratio, 0.79 [95% CI, 0.63–0.98]; P=0.03) without differences in various subgroups. Complications occurred more frequently in patients with left ventricular unloadingsevere bleeding in 98 (38.4%) versus 45 (17.9%), access site–related ischemia in 55 (21.6%) versus 31 (12.3%), abdominal compartment in 23 (9.4%) versus 9 (3.7%), and renal replacement therapy in 148 (58.5%) versus 99 (39.1%). CONCLUSIONS:In this international, multicenter cohort study, left ventricular unloading was associated with lower mortality in patients with cardiogenic shock treated with VA-ECMO, despite higher complication rates. These findings support use of left ventricular unloading in patients with cardiogenic shock treated with VA-ECMO and call for further validation, ideally in a randomized, controlled trial.