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Lüsebrink E, Binzenhöfer L, Hering D, Villegas Sierra L, Schrage B, Scherer C, Speidl WS, Uribarri A, Sabate M, Noc M, Sandoval E, Erglis A, Pappalardo F, De Roeck F, Tavazzi G, Riera J, Roncon-Albuquerque R, Meder B, Luedike P, Rassaf T, Hausleiter J, Hagl C, Zimmer S, Westermann D, Combes A, Zeymer U, Massberg S, Schäfer A, Orban M, Thiele H. Scrutinizing the Role of Venoarterial Extracorporeal Membrane Oxygenation: Has Clinical Practice Outpaced the Evidence? Circulation 2024; 149:1033-1052. [PMID: 38527130 DOI: 10.1161/circulationaha.123.067087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/27/2024]
Abstract
The use of venoarterial extracorporeal membrane oxygenation (VA-ECMO) for temporary mechanical circulatory support in various clinical scenarios has been increasing consistently, despite the lack of sufficient evidence regarding its benefit and safety from adequately powered randomized controlled trials. Although the ARREST trial (Advanced Reperfusion Strategies for Patients with Out-of-Hospital Cardiac Arrest and Refractory Ventricular Fibrillation) and a secondary analysis of the PRAGUE OHCA trial (Prague Out-of-Hospital Cardiac Arrest) provided some evidence in favor of VA-ECMO in the setting of out-of-hospital cardiac arrest, the INCEPTION trial (Early Initiation of Extracorporeal Life Support in Refractory Out-of-Hospital Cardiac Arrest) has not found a relevant improvement of short-term mortality with extracorporeal cardiopulmonary resuscitation. In addition, the results of the recently published ECLS-SHOCK trial (Extracorporeal Life Support in Cardiogenic Shock) and ECMO-CS trial (Extracorporeal Membrane Oxygenation in the Therapy of Cardiogenic Shock) discourage the routine use of VA-ECMO in patients with infarct-related cardiogenic shock. Ongoing clinical trials (ANCHOR [Assessment of ECMO in Acute Myocardial Infarction Cardiogenic Shock, NCT04184635], REVERSE [Impella CP With VA ECMO for Cardiogenic Shock, NCT03431467], UNLOAD ECMO [Left Ventricular Unloading to Improve Outcome in Cardiogenic Shock Patients on VA-ECMO, NCT05577195], PIONEER [Hemodynamic Support With ECMO and IABP in Elective Complex High-risk PCI, NCT04045873]) may clarify the usefulness of VA-ECMO in specific patient subpopulations and the efficacy of combined mechanical circulatory support strategies. Pending further data to refine patient selection and management recommendations for VA-ECMO, it remains uncertain whether the present usage of this device improves outcomes.
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Affiliation(s)
- Enzo Lüsebrink
- Department of Medicine I, LMU University Hospital, LMU Munich, Germany and DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance (E.L., L.B., D.H., L.V.S., C.S., J.H., S.M., M.O.)
| | - Leonhard Binzenhöfer
- Department of Medicine I, LMU University Hospital, LMU Munich, Germany and DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance (E.L., L.B., D.H., L.V.S., C.S., J.H., S.M., M.O.)
| | - Daniel Hering
- Department of Medicine I, LMU University Hospital, LMU Munich, Germany and DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance (E.L., L.B., D.H., L.V.S., C.S., J.H., S.M., M.O.)
| | - Laura Villegas Sierra
- Department of Medicine I, LMU University Hospital, LMU Munich, Germany and DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance (E.L., L.B., D.H., L.V.S., C.S., J.H., S.M., M.O.)
| | - Benedikt Schrage
- Department of Cardiology, University Heart and Vascular Center Hamburg, Germany and DZHK (German Center for Cardiovascular Research), partner site Hamburg/Kiel/Lübeck, Germany (B.S.)
| | - Clemens Scherer
- Department of Medicine I, LMU University Hospital, LMU Munich, Germany and DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance (E.L., L.B., D.H., L.V.S., C.S., J.H., S.M., M.O.)
| | - Walter S Speidl
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria (W.S.S.)
| | - Aitor Uribarri
- Cardiology Department, Vall d'Hebron Hospital Universitari, Vall d'Hebron Institut de Recerca (VHIR), Barcelona, Spain. CIBER-CV (A.U.)
| | - Manel Sabate
- Interventional Cardiology Department, Hospital Clinic, Instituto de Investigaciones Biomédicas August Pi i Sunyer (IDIBAPS), University of Barcelona, Spain (M.S.)
| | - Marko Noc
- Center for Intensive Internal Medicine, University Medical Center, Ljubljana, Slovenia (M.N.)
| | - Elena Sandoval
- Department of Cardiovascular Surgery, Hospital Clínic, Barcelona, Spain (E.S.)
| | - Andrejs Erglis
- Latvian Centre of Cardiology, Paul Stradins Clinical University Hospital, Riga, Latvia (A.E.)
| | - Federico Pappalardo
- Cardiothoracic and Vascular Anesthesia and Intensive Care Unit, AO SS. Antonio e Biagio e Cesare Arrigo, Alessandria, Italy (F.P.)
| | - Frederic De Roeck
- Department of Cardiology, Antwerp University Hospital, Edegem, Belgium (F.D.R.)
| | - Guido Tavazzi
- Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, University of Pavia Intensive Care, Fondazione IRCCS Policlinico San Matteo, Italy (G.T.)
| | - Jordi Riera
- Intensive Care Department, Vall d'Hebron University Hospital, and SODIR, Vall d'Hebron Research Institute, Barcelona, Spain (J.R.)
| | - Roberto Roncon-Albuquerque
- Department of Intensive Care Medicine, São João University Hospital Center, UnIC@RISE and Department of Surgery and Physiology, Faculty of Medicine of Porto, Portugal (R.R.-A.)
| | - Benjamin Meder
- Department of Cardiology, Angiology, and Pneumology, University Hospital Heidelberg, Germany (B.M.)
| | - Peter Luedike
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center, University Hospital Essen (P.L., T.R.)
| | - Tienush Rassaf
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center, University Hospital Essen (P.L., T.R.)
| | - Jörg Hausleiter
- Department of Medicine I, LMU University Hospital, LMU Munich, Germany and DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance (E.L., L.B., D.H., L.V.S., C.S., J.H., S.M., M.O.)
| | - Christian Hagl
- Department of Cardiac Surgery, LMU University Hospital, LMU Munich, Germany and DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance, Germany (C.H.)
| | - Sebastian Zimmer
- Department of Internal Medicine II, Heart Center Bonn, University Hospital Bonn, Venusberg-Campus 1, Germany (S.Z.)
| | - Dirk Westermann
- Department of Cardiology and Angiology, Medical Center, University of Freiburg, Germany (D.W.)
| | - Alain Combes
- Sorbonne Université, INSERM, UMRS_1166-ICAN, Institute of Cardiometabolism and Nutrition, Paris, France, and Service de Médecine Intensive-Réanimation, Institut de Cardiologie, APHP Sorbonne Université Hôpital Pitié-Salpêtrière, Paris, France (A.C.)
| | - Uwe Zeymer
- Klinikum der Stadt Ludwigshafen and Institut für Herzinfarktforschung, Ludwigshafen am Rhein, Germany (U.Z.)
| | - Steffen Massberg
- Department of Medicine I, LMU University Hospital, LMU Munich, Germany and DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance (E.L., L.B., D.H., L.V.S., C.S., J.H., S.M., M.O.)
| | - Andreas Schäfer
- Department of Cardiology and Angiology, Hannover Medical School, Germany (A.S.)
| | - Martin Orban
- Department of Medicine I, LMU University Hospital, LMU Munich, Germany and DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance (E.L., L.B., D.H., L.V.S., C.S., J.H., S.M., M.O.)
| | - Holger Thiele
- Heart Center Leipzig at University of Leipzig, Department of Internal Medicine/Cardiology and Leipzig Heart Science, Germany (H.T.)
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Sugimura Y, Immohr MB, Mehdiani A, Boeken U, Aubin H, Lichtenberg A, Akhyari P. Impact of Impella Support on Clinical Outcomes in Patients with Postcardiotomy Cardiogenic Shock. Ann Thorac Cardiovasc Surg 2024; 30:23-00076. [PMID: 37532525 PMCID: PMC10902663 DOI: 10.5761/atcs.oa.23-00076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Accepted: 07/10/2023] [Indexed: 08/04/2023] Open
Abstract
PURPOSE This study aimed to elucidate the strategy of an effective Impella support for better clinical outcomes in patients with a postcardiotomy cardiogenic shock (PCCS). METHODS This single-center retrospective observational study enrolled 31 patients with PCCS undergoing an elective open-heart surgery followed by Impella support between November 2018 and February 2022 for further analysis. RESULTS The preoperative Euroscore II and left ventricular (LV) ejection fraction were 9.1 ± 10.4 and 35.7% ± 12.6%, respectively. The in-hospital mortality rate was 51.6% (n = 16). In survivors (n = 15), the mean Impella support time was 6.9 ± 3.5 days. Patients were discharged on the postoperative day 24.9 ± 16.4. Regarding LV remodeling, LV end-diastolic diameter was significantly decreased after Impella support (59.2 ± 6.0 mm vs. 54.4 ± 4.7 mm, p = 0.01, preoperative vs. postoperative). In-hospital mortality rates were comparable with small (CP, n = 6) or large (5.0, n = 25) Impella systems (33.3% [n = 2] vs. 56.0% [n = 14], p = 0.39). However, a lower in-hospital mortality rate was observed in the group with early initiation (i.e., intraoperative) of Impella support (n = 14) than that with delayed Impella initiation (i.e., in the postoperative course) (n = 11) (28.6% [n = 4] vs. 90.9% [n = 10], p = 0.004). CONCLUSIONS Impella support contributes to LV remodeling in PCCS patients. In-hospital mortality was comparable in different Impella sizes and lower in early Impella initiation.
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Affiliation(s)
- Yukiharu Sugimura
- Department of Cardiac Surgery and Research Group for Experimental Surgery, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University Hospital, Düsseldorf, Germany
- Department of Cardiac Surgery, Medical Faculty and RWTH University Hospital Aachen, RWTH Aachen University, Aachen, Germany
| | - Moritz Benjamin Immohr
- Department of Cardiac Surgery and Research Group for Experimental Surgery, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University Hospital, Düsseldorf, Germany
- Department of Cardiac Surgery, Medical Faculty and RWTH University Hospital Aachen, RWTH Aachen University, Aachen, Germany
| | - Arash Mehdiani
- Department of Cardiac Surgery and Research Group for Experimental Surgery, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University Hospital, Düsseldorf, Germany
- Department of Cardiac Surgery, Medical Faculty and RWTH University Hospital Aachen, RWTH Aachen University, Aachen, Germany
| | - Udo Boeken
- Department of Cardiac Surgery and Research Group for Experimental Surgery, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University Hospital, Düsseldorf, Germany
| | - Hug Aubin
- Department of Cardiac Surgery and Research Group for Experimental Surgery, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University Hospital, Düsseldorf, Germany
| | - Artur Lichtenberg
- Department of Cardiac Surgery and Research Group for Experimental Surgery, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University Hospital, Düsseldorf, Germany
| | - Payam Akhyari
- Department of Cardiac Surgery and Research Group for Experimental Surgery, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University Hospital, Düsseldorf, Germany
- Department of Cardiac Surgery, Medical Faculty and RWTH University Hospital Aachen, RWTH Aachen University, Aachen, Germany
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Corujo Rodriguez A, Richter E, Ibekwe SO, Shah T, Faloye AO. Postcardiotomy Shock Syndrome: A Narrative Review of Perioperative Diagnosis and Management. J Cardiothorac Vasc Anesth 2023; 37:2621-2633. [PMID: 37806929 DOI: 10.1053/j.jvca.2023.09.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Revised: 08/29/2023] [Accepted: 09/09/2023] [Indexed: 10/10/2023]
Abstract
Postcardiotomy shock (PCS) is generally described as the inability to separate from cardiopulmonary bypass due to ineffective cardiac output after cardiotomy, which is caused by a primary cardiac disorder, resulting in inadequate tissue perfusion. Postcardiotomy shock occurs in 0.5% to 1.5% of contemporary cardiac surgery cases, and is accompanied by an in-hospital mortality of approximately 67%. In the last 2 decades, the incidence of PCS has increased, likely due to the increased age and baseline morbidity of patients requiring cardiac surgery. In this narrative review, the authors discuss the epidemiology and pathophysiology of PCS, the rationale and evidence behind the initiation, continuation, escalation, and discontinuation of mechanical support devices in PCS, and the anesthetic implications.
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Affiliation(s)
| | - Ellen Richter
- Department of Anesthesiology, Emory University, Atlanta, GA
| | | | - Tina Shah
- Department of Anesthesiology, Emory University, Atlanta, GA
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Zeng P, Yang C, Chen J, Fan Z, Cai W, Huang Y, Xiang Z, Yang J, Zhang J, Yang J. Comparison of the Efficacy of ECMO With or Without IABP in Patients With Cardiogenic Shock: A Meta-Analysis. Front Cardiovasc Med 2022; 9:917610. [PMID: 35872892 PMCID: PMC9300857 DOI: 10.3389/fcvm.2022.917610] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Accepted: 05/24/2022] [Indexed: 11/24/2022] Open
Abstract
Objective Studies on extracorporeal membrane oxygenation (ECMO) with and without an intra-aortic balloon pump (IABP) for cardiogenic shock (CS) have been published, but there have been no meta-analyses that compare the efficacy of these two cardiac support methods. This meta-analysis evaluated the outcomes of these two different treatment measures. Methods The PubMed, Embase, Cochrane Library, Web of Science, and Clinical Trials databases were searched until March 2022. Studies that were related to ECMO with or without IABP in patients with CS were screened. Quality assessments were evaluated with the methodological index for nonrandomized studies (MINORS). The primary outcome was in-hospital survival, while the secondary outcomes included duration of ECMO, duration of ICU stay, infection/sepsis, and bleeding. Revman 5.3 and STATA software were used for this meta-analysis. Results In total, nine manuscripts with 2,573 patients were included in the systematic review. CS patients who received ECMO in combination with IABP had significantly improved in-hospital survival compared with ECMO alone (OR = 1.58, 95% CI = 1.26–1.98, P < 0.0001). However, there were no significant differences in the duration of ECMO (MD = 0.36, 95% CI = −0.12–0.84, P = 0.14), duration of ICU stay (MD = −1.95, 95% CI = −4.05–0.15, P = 0.07), incidence of infection/sepsis (OR = 1.0, 95% CI = 0.58–1.72, P = 1.0), or bleeding (OR = 1.28, 95% CI = 0.48–3.45, P = 0.62) between the two groups of patients with CS. Conclusion ECMO combined with IABP can improve in-hospital survival more effectively than ECMO alone in patients with CS.
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Affiliation(s)
- Ping Zeng
- Department of Cardiology, The First College of Clinical Medical Science, China Three Gorges University and Yichang Central People's Hospital, Yichang, China
| | - Chaojun Yang
- Department of Cardiology, The First College of Clinical Medical Science, China Three Gorges University and Yichang Central People's Hospital, Yichang, China
| | - Jing Chen
- Hubei Key Laboratory of Cardiology, Department of Cardiology, Cardiovascular Research Institute, Renmin Hospital, Wuhan University, Wuhan, China
| | - Zhixing Fan
- Department of Cardiology, The First College of Clinical Medical Science, China Three Gorges University and Yichang Central People's Hospital, Yichang, China
| | - Wanyin Cai
- Department of Cardiology, The First College of Clinical Medical Science, China Three Gorges University and Yichang Central People's Hospital, Yichang, China
| | - Yifan Huang
- Department of Cardiology, The First College of Clinical Medical Science, China Three Gorges University and Yichang Central People's Hospital, Yichang, China
| | - Zujin Xiang
- Department of Cardiology, The First College of Clinical Medical Science, China Three Gorges University and Yichang Central People's Hospital, Yichang, China
| | - Jun Yang
- Department of Cardiology, The First College of Clinical Medical Science, China Three Gorges University and Yichang Central People's Hospital, Yichang, China
| | - Jing Zhang
- Department of Cardiology, The First College of Clinical Medical Science, China Three Gorges University and Yichang Central People's Hospital, Yichang, China
| | - Jian Yang
- Department of Cardiology, The First College of Clinical Medical Science, China Three Gorges University and Yichang Central People's Hospital, Yichang, China
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