Different strategies in left ventricle unloading during venoarterial extracorporeal membrane oxygenation: A network meta-analysis

Background

Left ventricular (LV) overload is a frequent complication during VA-ECMO associated with poor outcomes. Many strategies of LV unloading have been documented but lack of evidence shows which is better. We conducted a network meta-analysis to compare different LV unloading strategies.

Methods

We searched databases for all published studies on LV unloading strategies during VA-ECMO. The pre-defined primary outcome was all-cause mortality.

Results

45 observational studies (34235 patients) were included. The Surface Under the Cumulative Ranking values (SUCRA) demonstrated that compared to no unloading strategy (15.4 %), IABP (73.8 %), pLVAD (60.8 %), atrial septostomy (51.2 %), catheter venting (48.8 %) were all associated with decreased all-cause mortality, in which IABP and pLVAD existed statistical significance. For secondary outcomes, no unloading group had the shortest VA-ECMO duration, ICU and hospital length of stay, and the lower risk of complications compared with unloading strategies. IABP was associated with reducing VA-ECMO duration, ICU and hospital length of stay, and the risk of complications (except for hemolysis as the second best) compared with other unloading strategies.

Conclusions

LV unloading strategies during VA-ECMO were associated with improved survival compared to no unloading, but the tendency to increase the risk of various complications deserves more consideration.

Unloading in cardiogenic shock: the rationale and current evidence

PURPOSE OF REVIEW

Discussing the rationale and current evidence for left ventricular unloading in cardiogenic shock.

RECENT FINDINGS

Microaxial flow pumps (MFP) and intra-aortic balloon pumps (IABP) augment cardiac output while simultaneously unloading the left ventricle (e.g. reducing left ventricular pressure), thereby targeting a key mechanism of cardiogenic shock. A recent randomized trial has shown a mortality reduction with MFP in selected patients with cardiogenic shock, strengthening the rationale for this strategy, although the evidence for the IABP is so far neutral. MFP/IABP can also be used concomitantly with veno-arterial extracorporeal membrane oxygenation (va-ECMO) to alleviate the va-ECMO-related increase in left ventricular afterload, to facilitate weaning and ultimately to improve myocardial recovery and prognosis of affected patients. However, the use of MFP/IABP in this indication solely relies on retrospective data, which need to be interpreted with caution, especially as these strategies are associated with more complications. Currently ongoing randomized trials will help to further clarify the role of left ventricular unloading in patients on va-ECMO.

SUMMARY

Left ventricular unloading addresses a key mechanism of cardiogenic shock, with strong evidence to support MFP use in selected patients, but further randomized controlled trials are required to clarify the role of different devices/strategies for the overall shock population.

Increasing Sweep Gas Flow Reduces Respiratory Drive and Dyspnea in Nonintubated Venoarterial Extracorporeal Membrane Oxygenation Patients: A Pilot Study

BACKGROUND

Data on assessment and management of dyspnea in patients on venoarterial extracorporeal membrane oxygenation (ECMO) for cardiogenic shock are lacking. The hypothesis was that increasing sweep gas flow through the venoarterial extracorporeal membrane oxygenator may decrease dyspnea in nonintubated venoarterial ECMO patients exhibiting clinically significant dyspnea, with a parallel reduction in respiratory drive.

METHODS

Nonintubated, spontaneously breathing, supine patients on venoarterial ECMO for cardiogenic shock who presented with a dyspnea visual analog scale (VAS) score of greater than or equal to 40/100 mm were included. Sweep gas flow was increased up to +6 l/min by three steps of +2 l/min each. Dyspnea was assessed with the dyspnea-VAS and the Multidimensional Dyspnea Profile. The respiratory drive was assessed by the electromyographic activity of the alae nasi and parasternal muscles.

RESULTS

A total of 21 patients were included in the study. Upon inclusion, median dyspnea-VAS was 50 (interquartile range, 45 to 60) mm, and sweep gas flow was 1.0 l/min (0.5 to 2.0). An increase in sweep gas flow significantly decreased dyspnea-VAS (50 [45 to 60] at baseline vs. 20 [10 to 30] at 6 l/min; P < 0.001). The decrease in dyspnea was greater for the sensory component of dyspnea (-50% [-43 to -75]) than for the affective and emotional components (-17% [-0 to -25] and -12% [-0 to -17]; P < 0.001). An increase in sweep gas flow significantly decreased electromyographic activity of the alae nasi and parasternal muscles (-23% [-36 to -10] and -20 [-41 to -0]; P < 0.001). There was a significant correlation between the sweep gas flow and the dyspnea-VAS (r = -0.91; 95% CI, -0.94 to -0.87), between the respiratory drive and the sensory component of dyspnea (r = 0.29; 95% CI, 0.13 to 0.44) between the respiratory drive and the affective component of dyspnea (r = 0.29; 95% CI, 0.02 to 0.54) and between the sweep gas flow and the alae nasi and parasternal (r = -0.31; 95% CI, -0.44 to -0.22; and r = -0.25; 95% CI, -0.44 to -0.16).

CONCLUSIONS

In critically ill patients with venoarterial ECMO, an increase in sweep gas flow through the oxygenation membrane decreases dyspnea, possibly mediated by a decrease in respiratory drive.

EDITOR’S PERSPECTIVE

The physiology of venoarterial extracorporeal membrane oxygenation - A comprehensive clinical perspective

Venoarterial extracorporeal membrane oxygenation (VA ECMO) has become a standard of care for severe cardiogenic shock, refractory cardiac arrest and related impending multiorgan failure. The widespread clinical use of this complex temporary circulatory support modality is still contrasted by a lack of formal scientific evidence in the current literature. This might at least in part be attributable to VA ECMO related complications, which may significantly impact on clinical outcome. In order to limit adverse effects of VA ECMO as much as possible an indepth understanding of the complex physiology during extracorporeally supported cardiogenic shock states is critically important. This review covers all relevant physiological aspects of VA ECMO interacting with the human body in detail. This, to provide a solid basis for health care professionals involved in the daily management of patients supported with VA ECMO and suffering from cardiogenic shock or cardiac arrest and impending multiorgan failure for the best possible care.

Extracorporeal membrane oxygenation for postcardiotomy cardiogenic shock after valve replacement

BACKGROUND

Limited data evaluated the outcomes of extracorporeal membrane oxygenation (ECMO) in patients with prosthetic valves. This study aimed to compare the outcomes of ECMO support for postcardiotomy cardiogenic shock in patients with mechanical versus bioprosthetic valves.

METHODS

This retrospective study included patients with ECMO support for postcardiotomy cardiogenic shock after valve replacement. Patients were grouped into bioprosthetic (n = 49) and mechanical valve (n = 22) groups.

RESULTS

There were no differences in ECMO duration, inotropic support, intra-aortic balloon pump (IABP), stroke, duration of ICU, and hospital stay between groups. Postoperative thrombosis occurred in 2 patients with bioprosthetic valves (5.41%) and 2 with mechanical valves (14.29%), p = .30. All patients with thrombosis had central ECMO cannulation, concomitant IABP, and inotropic support during ECMO. All thrombi were related to the mitral valve. Three patients with thrombi had hospital mortality.Survival at 6, 12, and 36 months for bioprosthetic valve patients was 30.88%, 28.55%, and 25.34% and for mechanical valves was 36.36% for all time intervals (Log-rank p = .93). One patient had bioprosthetic aortic valve endocarditis after 1 year. Three patients with bioprosthetic valves had structural valve degeneration after 1, 2, and 5 years.

CONCLUSIONS

Outcomes of ECMO in patients with prosthetic valves are comparable between bioprosthetic and mechanical valves. Thrombosis might occur in both valve types and was associated with high mortality. ECMO could affect the long-term durability of the bioprosthetic valves.

Scrutinizing the Role of Venoarterial Extracorporeal Membrane Oxygenation: Has Clinical Practice Outpaced the Evidence?

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.

Venoarterial extracorporeal membrane oxygenation in immunocompromised patients with cardiogenic shock: a cohort study and propensity-weighted analysis

PURPOSE

The outcomes of immunocompromised patients with cardiogenic shock treated with venoarterial extracorporeal membrane oxygenation (VA-ECMO) are seldom documented, making ECMO candidacy decisions challenging. This study aims (1) to report outcomes of immunocompromised patients treated with VA-ECMO, (2) to identify pre-ECMO predictors of 90-day mortality, (3) to assess the impact of immunodepression on 90-day mortality, and (4) to describe the main ECMO-related complications.

METHODS

This is a retrospective, propensity-weighted study conducted in two French experienced ECMO centers.

RESULTS

From January 2006 to January 2022, 177 critically ill immunocompromised patients (median (interquartile range, IQR) age 49 (32-60) years) received VA-ECMO. The main causes of immunosuppression were long-term corticosteroids/immunosuppressant treatment (29%), hematological malignancy (26%), solid organ transplant (20%), and solid tumor (13%). Overall 90-day and 1-year mortality were 70% (95% confidence interval (CI) 63-77%) and 75% (95% CI 65-79%), respectively. Older age and higher pre-ECMO lactate were independently associated with 90-day mortality. Across immunodepression causes, 1-year mortality ranged from 58% for patients with infection by human immunodeficiency virus (HIV) or asplenia, to 89% for solid organ transplant recipients. Hemorrhagic and infectious complications affected 39% and 54% of patients, while more than half the stay in intensive care unit (ICU) was spent on antibiotics. In a propensity score-weighted model comparing the 177 patients with 942 non-immunocompromised patients experiencing cardiogenic shock on VA-ECMO, immunocompromised status was independently associated with a higher 90-day mortality (odds ratio 2.53, 95% CI 1.72-3.79).

CONCLUSION

Immunocompromised patients undergoing VA-ECMO treatment face an unfavorable prognosis, with higher 90-day mortality compared to non-immunocompromised patients. This underscores the necessity for thorough evaluation and careful selection of ECMO candidates within this frail population.

Pulse pressure within the first 2 days of veno-arterial extracorporeal membrane oxygenation is predictive of death prior to hospital discharge, renal dysfunction requiring dialysis and pulmonary oedema

BACKGROUND

Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) flows are titrated to achieve adequate perfusion while attempting to ideally maintain arterial pulse pressure (PP). We assessed risk in patients with low PP defined as <10 mmHg within the first 2 days of support.

METHODS

Demographics, haemodynamics, echocardiographic and radiological findings were recorded retrospectively in cases conducted between 2014 and 2016. Outcomes were hospital mortality, requirement for renal replacement therapy (RRT) and severe pulmonary oedema (PO).

RESULTS

Of 101 patients, 66.3% were male, mean age was 56 (range 18-71 years), mean duration of support was 6.3 days ± 4.1 days, 37.6% died prior to hospital discharge, 39.6% needed RRT and 11.9% had severe PO. Areas under the receiver operating curves of PP at 48 h for hospital mortality, RRT and severe PO were (respectively): 0.69 (95% CI 0.58-0.80, p = .001), 0.64 (95% CI 0.50-0.77, p = .044), 0.69 (95% CI 0.55-0.82, p = .009). The odds ratio for mortality, RRT, severe PO for those with low PP were (respectively) 2.8 (95% CI 1.01-7.5, p = .04), 3.1 (95% CI 1.11-8.40, p = .026), 7.6 (95% CI 2.06-27.89, p = .001). Central venous pressure, mean arterial pressure were not predictive.

CONCLUSION

PP during the first 2 days of support is predictive of clinically important outcomes in patients supported with VA-ECMO.

Perspectives and Considerations of IABP in the Era of ECMO for Cardiogenic Shock

The development of mechanical circulatory support (MCS) has been rapid, and its use worldwide in patients with cardiogenic shock is increasingly widespread. However, current statistical data and clinical research do not demonstrate its significant improvement in the patient prognosis. This review focuses on the widely used intra-aortic balloon pumps (IABP) and veno-arterial extracorporeal membrane oxygenation (VA-ECMO), analyzing and comparing their characteristics, efficacy, risk of complications, and the current exploration status of left ventricular mechanical unloading. Subsequently, we propose a rational approach to viewing the negative outcomes of current MCS, and look ahead to the future development trends of IABP.

FX06 to rescue SARS-CoV-2-induced acute respiratory distress syndrome: a randomized clinical trial

BACKGROUND

Vascular leakage is a major feature of acute respiratory distress syndrome (ARDS). We aimed to evaluate the efficacy of FX06, a drug under development that stabilizes interendothelial cell junctions, at reducing vascular leakage during SARS-CoV-2-induced ARDS.

METHODS

This multicenter, double-blinded, randomized trial included adults with COVID-19-associated ARDS who had received invasive mechanical ventilation for < 5 days and were randomized to receive either intravenous FX06 (400 mg/d, for 5 days) or its vehicle as placebo. The primary endpoint was the lowering-from day 1 to day 7-of the transpulmonary thermodilution-derived extravascular lung-water index (EVLWi).

RESULTS

Twenty-five patients were randomized to receive FX06 and 24 the placebo. Although EVLWi was elevated at baseline (median [IQR] 15.6 mL/kg [13.5; 18.5]), its declines from day 1 to day 7 were comparable for FX06 recipients and controls (respectively, - 1.9 [- 3.3; - 0.5] vs. - 0.8 [- 5.5; - 1.1] mL/kg; estimated effect - 0.8 [- 3.1; + 2.4], p = 0.51). Cardiac indexes, pulmonary vascular permeability indexes, and fluid balances were also comparable, as were PaO2/FiO2 ratios and durations of mechanical ventilation. Adverse event rates were similar for the 2 groups, although more FX06 recipients developed ventilator-associated pneumonia (16/25 (64%) vs. 6/24 (24%), p = 0.009).

CONCLUSIONS

In this unique-dosing-regimen study, FX06 did not lower SARS-CoV-2-induced pulmonary vascular leakage. Future investigations will need to evaluate its efficacy at earlier times during the disease or using other regimens. Trial registration NCT04618042. Registered 5 November 2020.

Effect of intra-aortic balloon pump with veno-arterial extracorporeal membrane oxygenation in acute myocardial infarction with cardiogenic shock: A meta-analysis

BACKGROUND

The effectiveness of a concomitant intra-aortic balloon pump (IABP) with veno-arterial extracorporeal membrane oxygenation (VA-ECMO) intervention in acute myocardial infarction with cardiogenic shock (AMICS) patients is contested in the literature. This study sought to compare short-term mortality weaning rate from VA-ECMOin AMICS cases.

METHODS

We conducted a literature review and compared the primary and secondary endpoints in the following treatment groups of AMICS patients: (1) VA-ECMO plus IABP vs. IABP alone and (2) VA-ECMO plus IABP vs. VA-ECMO alone. The primary endpoint was in-hospital all-cause mortality; while 30-days mortality, weaning from VA-ECMO, and vascular complications comprised secondary endpoints.

RESULTS

VA-ECMO concomitant with IABP was administered to 3,580 (76.4%) patients, while IABP alone and VA-ECMO alone treatments accounted for 1.7% and 21.9% of the patients, respectively. We found that in-hospital mortality was significantly lower in patients treated with VA-ECMO plus IABP vs. VA-ECMO alone (odds ratio (OR) = 0.52; 95% Confidence Interval (CI) = 0.21-1.31; I-squared statistic (I2 = 30%) or IABP alone (OR = 0.20; 95% CI = 0.08-0.55; I2 = 0%). Additionally, 30-days mortality was significantly lower in patients treated with VA-ECMO plus IABP vs. VA-ECMO alone (OR = 0.31; 95% CI = 0.25-0.40; I2 = 0%) or IABP alone (OR = 0.24; 95% CI = 0.11-0.50; I2 = 0%). A significant difference was observed in weaning from VA-ECMO in patients treated with VA-ECMO plus IABP vs. VA-ECMO alone (OR = 1.91; 95% CI = 1.09-3.33; I2 = 0%).

CONCLUSION

In-hospital and 30-days mortality were significantly lower in AMICS patients treated with VA-ECMO plus IABP vs. VA-ECMO alone or IABP alone. VA-ECMO with concomitant IABP could increase the proportion of patients weaned from VA-ECMO, significantly reducing in-hospital mortality, without increasing complications.

Lung ultrasound to evaluate pulmonary changes in patients with cardiogenic shock undergoing extracorporeal membrane oxygenation: a retrospective study

PURPOSE

The aim of the study was to evaluate the value of lung ultrasound (LUS) in patients with cardiogenic shock treated by venoarterial extracorporeal membrane oxygenation (VA-ECMO).

METHODS

A retrospective study was conducted in Xuzhou Central Hospital from September 2015 to April 2022. Patients with cardiogenic shock who received VA-ECMO treatment were enrolled in this study. The LUS score was obtained at the different time points of ECMO.

RESULTS

Twenty-two patients were divided into a survival group (n = 16) and a nonsurvival group (n = 6). The intensive care unit (ICU) mortality was 27.3% (6/22). The LUS scores in the nonsurvival group were significantly higher than those in the survival group after 72 h (P < 0.05). There was a significant negative correlation between LUS scores and PaO₂/FiO₂ and LUS scores and pulmonary dynamic compliance(Cdyn) after 72 h of ECMO treatment (P < 0.001). ROC curve analysis showed that the area under the ROC curve (AUC) of T₇₂-LUS was 0.964 (95% CI 0.887 ~ 1.000, P < 0.01).

CONCLUSION

LUS is a promising tool for evaluating pulmonary changes in patients with cardiogenic shock undergoing VA-ECMO.

TRIAL REGISTRATION

The study had been registered in the Chinese Clinical Trial Registry(NO.ChiCTR2200062130 and 24/07/2022).

Concomitant intra-aortic balloon pump and veno-arterial extracorporeal membrane oxygenation for postcardiotomy cardiogenic shock

We aimed to compare the outcomes of ECMO with and without IABP for postcardiotomy cardiogenic shock. The study included 103 patients who needed ECMO for postcardiotomy cardiogenic shock. Patients were grouped according to the use of IABP into ECMO without IABP (n = 43) and ECMO with IABP (n = 60). The study endpoints were hospital complications, successful weaning, and survival. Patients with IABP had lower preoperative ejection fraction (p = 0.002). There was no difference in stroke (p = 0.97), limb ischemic (p = 0.32), and duration of ICU stay (p = 0.11) between groups. Successful weaning was non-significantly higher with IABP (36 (60%) vs 19 (44.19%); p = 0.11). Predictors of successful weaning were inversely related to the high pre-ECMO lactate levels (OR: 0.89; p = 0.01), active endocarditis (OR: 0.06; p = 0.02), older age (OR: 0.95; p = 0.02), and aortic valve replacement (OR: 0.26; p = 0.04). There was no difference in survival between groups (p = 0.80). Our study did not support the routine use of IABP during ECMO support.

Unloading the Left Ventricle in Venoarterial ECMO: In Whom, When, and How?

Venoarterial extracorporeal membrane oxygenation provides cardiorespiratory support to patients in cardiogenic shock. This comes at the cost of increased left ventricle (LV) afterload that can be partly ascribed to retrograde aortic flow, causing LV distension, and leads to complications including cardiac thrombi, arrhythmias, and pulmonary edema. LV unloading can be achieved by using an additional circulatory support device to mitigate the adverse effects of mechanical overload that may increase the likelihood of myocardial recovery. Observational data suggest that these strategies may improve outcomes, but in whom, when, and how LV unloading should be employed is unclear; all techniques require balancing presumed benefits against known risks of device-related complications. This review summarizes the current evidence related to LV unloading with venoarterial extracorporeal membrane oxygenation.

Pulmonary Protection from Left Ventricular Distension During Venoarterial Extracorporeal Membrane Oxygenation: Review and Management Algorithm

The use of venoarterial extracorporeal membrane oxygenation (VA-ECMO) in adults for refractory cardiogenic shock has risen exponentially during the prior decade. Although VA-ECMO provides cardiopulmonary support, it can alter left ventricular (LV) loading conditions leading to LV distension, which makes the lungs susceptible to congestion and promotes intracardiac thrombosis. These conditions can be alleviated by pharmacologic and mechanical unloading, but gaps in knowledge remain on optimal timing and methods of this approach. This review provides an overview of the epidemiology of VA-ECMO, describes pathophysiology and methods for monitoring and reducing LV loading and summarizes contemporary studies examining the association between LV unloading and adverse events. We offer a simple protocol for implementing LV unloading during VA-ECMO to provide pulmonary protection and improve outcomes.

Adjusted mortality of extracorporeal membrane oxygenation for acute myocardial infarction patients in cardiogenic shock

Cardiogenic shock (CS) is a common cause of death following acute myocardial infarction (MI). This study aimed to evaluate the adjusted mortality of venoarterial extracorporeal membrane oxygenation (VA-ECMO) with intra-aortic balloon counterpulsation (IABP) for patients with MI-CS. We included 300 MI patients selected from a multinational registry and categorized into VA-ECMO + IABP (N = 39) and no VA-ECMO (medical management ± IABP) (N = 261) groups. Both groups' 30-day and 1-year mortality were compared using the weighted Kaplan-Meier, propensity score, and inverse probability of treatment weighting methods. Adjusted incidences of 30-day (VA-ECMO + IABP vs No VA-ECMO, 77.7% vs 50.7; P = .083) and 1-year mortality (92.3% vs 84.8%; P = .223) along with propensity-adjusted and inverse probability of treatment weighting models in 30-day (hazard ratio [HR], 1.57; 95% confidence interval [CI], 0.92-2.77; P = .346 and HR, 1.44; 95% CI, 0.42-3.17; P = .452, respectively) and 1-year mortality (HR, 1.56; 95% CI, 0.95-2.56; P = .076 and HR, 1.33; 95% CI, 0.57-3.06; P = .51, respectively) did not differ between the groups. However, better survival benefit 30 days post-ECMO could be supposed (31.6% vs 83.4%; P = .022). Therefore, patients with MI-CS treated with IABP with additional VA-ECMO and those not supported with ECMO have comparable overall 30-day and 1-year mortality risks. However, VA-ECMO-supported survivors might have better long-term clinical outcomes.

Association Between Shock Etiology and 5-Year Outcomes After Venoarterial Extracorporeal Membrane Oxygenation

BACKGROUND

Outcomes of patients requiring venoarterial extracorporeal membrane oxygenation (VA-ECMO) vary greatly by etiology, but large studies that incorporate the spectrum of shock supported with ECMO are rare.

OBJECTIVES

The purpose of this study was to describe the etiology-related outcome of patients with shock supported with peripheral VA-ECMO.

METHODS

All consecutive adults with peripheral VA-ECMO between January 2015 and August 2018 at Pitié-Salpêtrière Hospital (Paris, France) were included in this retrospective observational study. The indication for VA-ECMO was cardiogenic shock. Rates of hospital death and neurological, renal, and pulmonary complications were evaluated according to etiology.

RESULTS

Among 1,253 patients, hospital and 5-year survival rates were, respectively, 73.3% and 57.3% for primary graft failure, 58.6% and 54.0% for drug overdose, 53.2% and 45.3% for dilated cardiomyopathy, 51.6% and 50.0% for arrhythmic storm, 46.8% and 38.3% for massive pulmonary embolism, 44.4% and 42.4% for sepsis-induced cardiogenic shock, 37.9% and 32.9% for fulminant myocarditis, 37.3% and 31.5% for acute myocardial infarction, 34.6% and 33.3% for postcardiotomy excluding primary graft failure, 25.7% and 22.8% for other/unknown etiology, and 11.1% and 0.0% for refractory vasoplegia shock. Renal failure requiring hemodialysis developed in 50.0%, neurological complications in 16.0%, and hydrostatic pulmonary edema in 9.0%.

CONCLUSIONS

Although the outcome differs depending on etiology, this difference is related more to the severity of the situation associated with the cause rather than the cause of the shock per se. Survival to 5 years varied by cause, which may reflect the natural course of the chronic disease and illustrates the need for long-term follow-up.

Quantitative evaluation of hemodynamic parameters by echocardiography in patients with post-cardiotomy cardiac shock supported by extracorporeal membrane oxygenation

BACKGROUND

When drugs fail to reverse post-cardiotomy cardiac shock (PCS), extracorporeal membrane oxygenation (ECMO) is considered the most effective adjuvant strategy. Transthoracic echocardiography is a useful imaging modality for monitoring of cardiac hemodynamics. The aim of this study was to investigate the value of echocardiography for monitoring the left and right heart hemodynamics in PCS patients before, during, and after weaning from ECMO.

METHODS

Fifty-two patients were divided into successful weaning group (group A, n = 23) and non-successful weaning group (group B, n = 29). Hemodynamic parameters measured by echocardiography were collected before, during, and after ECMO. The intra-group changes and inter-group differences were retrospectively analyzed.

RESULTS

In group A, the central venous pressure (CVP), proximal right ventricular outflow tract (RVOT), tricuspid annular plane systolic excursion (TAPSE), velocity of tricuspid valve (TVDV), and systolic velocity of tricuspid annulus ([Formula: see text]) during ECMO were significantly lower than those before ECMO. After ECMO, left ventricular ejection fraction (LVEF), systolic velocity of mitral annulus ([Formula: see text]), and velocity-time integral of LV outflow tract (LVOT-VTI) were higher than pre-ECMO levels, and CVP, LVEF, [Formula: see text], LVOT-VTI, RVOT, TAPSE, TVDV and [Formula: see text] were higher than those during ECMO (all P < 0.05). In group B, compared to pre-ECMO, subjects exhibited decreased CVP, RVOT, TAPSE, TVDV and [Formula: see text] during ECMO. TAPSE, TVDV, and [Formula: see text] were continuously lower after ECMO, while CVP and RVOT increased after ECMO (all P < 0.05). After ECMO, LVEF, [Formula: see text], LVOT-VTI, TAPSE, TVDV and [Formula: see text] in group A were higher than those in group B (all P < 0.05). Inter-group comparison showed the LVEF and RV Tei indices of group A were significantly different than those of group B before, during, and after ECMO.

CONCLUSION

Quantitative assessment of both LV and RV by echocardiography is important for ECMO weaning. Patients with better LVEF and lower RV Tei index may have a better chance of successful weaning from ECMO.

Veno-arterial extracorporeal membrane oxygenation with concomitant Impella versus concomitant intra-aortic-balloon-pump for cardiogenic shock

INTRODUCTION

The intra-aortic balloon pump (IABP) and Impella are left ventricular unloading devices with peripheral venoarterial extracorporeal membrane oxygenation (VA-ECMO) in place and later serve as bridging therapy when VA-ECMO is terminated. We aimed to determine the potential differences in clinical outcomes and rate of complications between the two combinations of mechanical circulatory support.

METHODS

This was a retrospective, single institutional cohort study conducted in the intensive care unit (ICU) of Queen Elizabeth Hospital, Hong Kong. Inclusion criteria included all patients aged ⩾18 years, who had VA-ECMO support, and who had left ventricular unloading by either IABP or Impella between January 1, 2018 and October 31, 2020. Patients <18 years old, with central VA-ECMO, who did not require left ventricular unloading, or who underwent surgical venting procedures were excluded. The primary outcome was ECMO duration. Secondary outcomes included length of stay (LOS) in the ICU, hospital LOS, mortality, and complication rate.

RESULTS

Fifty-two patients with ECMO + IABP and 14 patients with ECMO + Impella were recruited. No statistically significant difference was observed in terms of ECMO duration (2.5 vs 4.6 days, p = 0.147), ICU LOS (7.7 vs 10.8 days, p = 0.367), and hospital LOS (14.8 vs 16.5 days, p = 0.556) between the two groups. No statistically significant difference was observed in the ECMO, ICU, and hospital mortalities between the two groups. Specific complications related to the ECMO and Impella combination were also noted.

CONCLUSIONS

Impella was not shown to offer a statistically significant clinical benefit compared with IABP in conjunction with ECMO. Clinicians should be aware of the specific complications of using Impella.

Concomitant Intra-Aortic Balloon Pumping Significantly Reduces Left Ventricular Pressure during Central Veno-Arterial Extracorporeal Membrane Oxygenation-Results from a Large Animal Model

(1) Introduction: Simultaneous ECMO and IABP therapy is frequently used. Haemodynamic changes responsible for the success of the concomitant mechanical circulatory support system approach are rarely investigated. In a large-animal model, we analysed haemodynamic parameters before and during ECMO therapy, comparing central and peripheral ECMO circulation with and without simultaneous IABP support. (2) Methods: Thirty-three female pigs were divided into five groups: (1) SHAM, (2) (peripheral)ECMO(-)IABP, (3) (p)ECMO(+)IABP, (4) (central)ECMO(-)IABP, and (5) (c)ECMO(+)IABP. Pigs were cannulated in accordance with the group and supported with ECMO (±IABP) for 10 h. Systemic haemodynamics, cardiac index (CI), and coronary and carotid artery blood flow were determined before, directly after, and at five and ten hours on extracorporeal support. Systemic inflammation (IL-6; IL-10; TNFα; IFNγ), immune response (NETs; cf-DNA), and endothelial injury (ET-1) were also measured. (3) Results: IABP support during antegrade ECMO circulation led to a significant reduction of left ventricular pressure in comparison to retrograde flow in (p)ECMO(-)IABP and (p)ECMO(+)IABP. Blood flow in the left anterior coronary and carotid artery was not affected by extracorporeal circulation. (4) Conclusions: Concomitant central ECMO and IABP therapy leads to significant reduction of intracavitary cardiac pressure, reduces cardiac work, and might therefore contribute to improved recovery in ECMO patients.

Time course, factors related to, and prognostic impact of venoarterial extracorporeal membrane flow in cardiogenic shock

AIMS

Venoarterial extracorporeal membrane oxygenation (VA-ECMO) is currently one of the most used devices in refractory cardiogenic shock. However, there is a lack of evidence on how to set the 'optimal' flow. We aimed to describe the evolution of VA-ECMO flows in a cardiogenic shock population and determine the risk factors of 'high-ECMO flow'.

METHODS AND RESULTS

A 7 year database of patients supported with VA-ECMO was used. Based on the median flow during the first 48 h of the VA-ECMO run, patients were classified as 'high-flow' or 'low-flow', respectively, when median ECMO flow was ≥3.6 or <3.6 L/min. Outcomes included rates of ventilator-associated pneumonia, ECMO-related complications, days on ECMO, days on mechanical ventilation, intensive care unit and hospitalization lengths of stay, and in-hospital and 60 day mortality. Risk factors of high-ECMO flow were assessed using univariate and multivariate cox regression. The study population included 209 patients on VA-ECMO, median age was 51 (40-59) years, and 78% were males. The most frequent aetiology leading to cardiogenic shock was end-stage dilated cardiomyopathy (57%), followed by acute myocardial infarction (23%) and fulminant myocarditis (17%). Among the 209 patients, 105 (50%) were classified as 'high-flow'. This group had a higher rate of ischaemic aetiology (16% vs. 30%, P = 0.023) and was sicker at admission, in terms of worse Simplified Acute Physiology Score II score [40 (26-58) vs. 56 (42-74), P < 0.001], higher lactate [3.6 (2.2-5.8) mmol/L vs. 5.2 (3-9.7) mmol/L, P < 0.001], and higher aspartate aminotransferase [97 (41-375) U/L vs. 309 (85-939) U/L, P < 0.001], among others. The 'low-flow' group had less ventilator-associated pneumonia (40% vs. 59%, P = 0.007) and less days on mechanical ventilation [4 (1.5-7.5) vs. 6 (3-12) days, P = 0.009]. No differences were found in lengths of stay or survival according to the ECMO flow. The multivariate analysis showed that risk factors independently associated with 'high-flow' were mechanical ventilation at cannulation [odds ratio (OR) 3.9, 95% confidence interval (CI) 2.1-7.1] and pre-ECMO lactate (OR 1.1, 95% CI 1.0-1.2).

CONCLUSIONS

In patients with refractory cardiogenic shock supported with VA-ECMO, sicker patients had higher support since early phases, presenting thereafter higher rates of ventilator-associated pneumonia but similar survival compared with patients with lower flows.

Empfehlungen der S3-Leitlinie (AWMF) „Einsatz der extrakorporalen Zirkulation (ECLS/ECMO) bei Herz- und Kreislaufversagen“

In den vergangenen Jahren hat der Einsatz mechanischer Unterstützungssysteme für Patienten mit Herz- und Kreislaufversagen kontinuierlich zugenommen, sodass in Deutschland mittlerweile jährlich etwa 3000 ECLS-/ECMO-Systeme implantiert werden. Vor dem Hintergrund bislang fehlender umfassender Leitlinien bestand ein dringlicher Bedarf an der Formulierung evidenzbasierter Empfehlungen zu den zentralen Aspekten der ECLS-/ECMO-Therapie. Im Juli 2015 wurde daher die Erstellung einer S3-Leitlinie durch die Deutsche Gesellschaft für Thorax-, Herz- und Gefäßchirurgie (DGTHG) bei der zuständigen Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften e. V. (AWMF) angemeldet. In einem strukturierten Konsensusprozess mit Einbindung von Experten aus Deutschland, Österreich und der Schweiz, delegiert aus 11 AWMF-Fachgesellschaften, 5 weiteren Fachgesellschaften sowie der Patientenvertretung, entstand unter Federführung der DGTHG die Leitlinie „Einsatz der extrakorporalen Zirkulation (ECLS/ECMO) bei Herz- und Kreislaufversagen“, die im Februar 2021 publiziert wurde. Die Leitlinie fokussiert auf klinische Aspekte der Initiierung, Fortführung, Entwöhnung und Nachsorge und adressiert hierbei auch strukturelle und ökonomische Fragestellungen. Dieser Artikel präsentiert eine Übersicht zu der Methodik und den konsentierten Empfehlungen.

Hemodynamic Effect of Pulsatile on Blood Flow Distribution with VA ECMO: A Numerical Study

The pulsatile properties of arterial flow and pressure have been thought to be important. Nevertheless, a gap still exists in the hemodynamic effect of pulsatile flow in improving blood flow distribution of veno-arterial extracorporeal membrane oxygenation (VA ECMO) supported by the circulatory system. The finite-element models, consisting of the aorta, VA ECMO, and intra-aortic balloon pump (IABP) are proposed for fluid-structure interaction calculation of the mechanical response. Group A is cardiogenic shock with 1.5 L/min of cardiac output. Group B is cardiogenic shock with VA ECMO. Group C is added to IABP based on Group B. The sum of the blood flow of cardiac output and VA ECMO remains constant at 4.5 L/min in Group B and Group C. With the recovery of the left ventricular, the flow of VA ECMO declines, and the effective blood of IABP increases. IABP plays the function of balancing blood flow between left arteria femoralis and right arteria femoralis compared with VA ECMO only. The difference of the equivalent energy pressure (dEEP) is crossed at 2.0 L/min to 1.5 L/min of VA ECMO. PPI’ (the revised pulse pressure index) with IABP is twice as much as without IABP. The intersection with two opposing blood generates the region of the aortic arch for the VA ECMO (Group B). In contrast to the VA ECMO, the blood intersection appears from the descending aorta to the renal artery with VA ECMO and IABP. The maximum time-averaged wall shear stress (TAWSS) of the renal artery is a significant difference with or not IABP (VA ECMO: 2.02 vs. 1.98 vs. 2.37 vs. 2.61 vs. 2.86 Pa; VA ECMO and IABP: 8.02 vs. 6.99 vs. 6.62 vs. 6.30 vs. 5.83 Pa). In conclusion, with the recovery of the left ventricle, the flow of VA ECMO declines and the effective blood of IABP increases. The difference between the equivalent energy pressure (EEP) and the surplus hemodynamic energy (SHE) indicates the loss of pulsation from the left ventricular to VA ECMO. 2.0 L/min to 1.5 L/min of VA ECMO showing a similar hemodynamic energy loss with the weak influence of IABP.

Venting during venoarterial extracorporeal membrane oxygenation

Cardiogenic shock and cardiac arrest contribute pre-dominantly to mortality in acute cardiovascular care. Here, veno-arterial extracorporeal membrane oxygenation (VA-ECMO) has emerged as an established therapeutic option for patients suffering from these life-threatening entities. VA-ECMO provides temporary circulatory support until causative treatments are effective and enables recovery or serves as a bridging strategy to surgical ventricular assist devices, heart transplantation or decision-making. However, in-hospital mortality rate in this treatment population is still around 60%. In the recently published ARREST trial, VA-ECMO treatment lowered mortality rate in patients with ongoing cardiac arrest due to therapy refractory ventricular fibrillation compared to standard advanced cardiac life support in selected patients. Whether VA-ECMO can reduce mortality compared to standard of care in cardiogenic shock has to be evaluated in the ongoing prospective randomized studies EURO-SHOCK (NCT03813134) and ECLS-SHOCK (NCT03637205). As an innate drawback of VA-ECMO treatment, the retrograde aortic flow could lead to an elevation of left ventricular (LV) afterload, increase in LV filling pressure, mitral regurgitation, and elevated left atrial pressure. This may compromise myocardial function and recovery, pulmonary hemodynamics—possibly with concomitant pulmonary congestion and even lung failure—and contribute to poor outcomes in a relevant proportion of treated patients. To overcome these detrimental effects, a multitude of venting strategies are currently engaged for both preventive and emergent unloading. This review aims to provide a comprehensive and structured synopsis of existing venting modalities and their specific hemodynamic characteristics. We discuss in detail the available data on outcome categories and complication rates related to the respective venting option.

Graphical abstract

Mechanical Circulatory Support in Delayed Surgery of Post-Infarction Ventricular Septal Rupture in Patients in Cardiogenic Shock-A Review

Post-infarction ventricular septal rupture (VSR) is a serious complication of myocardial infarction, which, in its natural course or treated medically, is related to high mortality rate. Surgical intervention remains the treatment of choice. Recent studies have shown that delayed surgery is related to better outcomes in comparison with urgent surgery; however, in many studies the impact of the patients' initial hemodynamic status on the treatment outcomes often remains unclear. In this review, we analyze the outcomes of delayed surgical treatment of patients in cardiogenic shock in the course of post-infarction ventricular septal defect stabilized with preoperative use of mechanical circulatory support. We evaluate the importance of various types of mechanical circulatory devices (MCD), such as extracorporeal membrane oxygenation, Tandem Heart, Impella, and intra-aortic baloon pump (IABP) in preoperative stabilization of patients, and the most suitable time for surgery, and we also present the features of ideal MCD for patients with VSR. A search of Pubmed to identify studies concerning the use of MCD in patients in cardiogenic shock in the course of VSR qualified for delayed surgery was conducted in January 2022. A total of 16 articles with three or more patients described were analyzed in this study. The preoperative use of MCD in patients in cardiogenic shock and delayed surgery as a main part of treatment seems to be a promising direction, however, it requires further research.

How to Optimize ECLS Results beyond Ventricular Unloading: From ECMO to CentriMag® eVAD

CentriMag^® extracorporeal VAD support could represent a more physiological choice than conventional ECMO in primary cardiogenic shock. We therefore evaluated the outcome of patients with primary cardiogenic shock who were supported with CentriMag^® extracorporeal VAD implantation versus conventional ECMO. We retrospectively reviewed all extracorporeal life supports implanted for primary cardiogenic shock between January 2009 and December 2018 at our institution. Among 212 patients, 143 cases (67%) were treated exclusively with ECMO (Group 1) and 69 cases (33%) with extracorporeal VAD implantation (Group 2, 48 of whom as conversion of ECMO). ECLS mean duration was 8.37 ± 8.43 days in Group 1 and 14.25 ± 10.84 days in Group 2 (p = 0.001), while the mean rates of the highest predicted flow were 61.21 ± 16.01% and 79.49 ± 18.42% (p = 0.001), respectively. Increasing mechanical support flow was related to in-hospital mortality and overall mortality in Group 1 (HR 11.36, CI 95%: 2.19–44.20), but not in Group 2 (HR 1.48, CI 95%: 0.32–6.80). High-flow ECMO patients had lower survival with respect to high-flow extracorporeal VAD patients (p = 0.027). In the setting of high-flow mechanical circulatory support, CentriMag^® extracorporeal VAD optimized patient survival, granting long-term assistance and physiological circulation patterns.

Comparison of the Efficacy of ECMO With or Without IABP in Patients With Cardiogenic Shock: A Meta-Analysis

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.

Empfehlungen der S3-Leitlinie (AWMF) Einsatz der extrakorporalen Zirkulation (ECLS/ECMO) bei Herz- und Kreislaufversagen

In den vergangenen Jahren hat der Einsatz mechanischer Unterstützungssysteme für Patienten mit Herz- und Kreislaufversagen kontinuierlich zugenommen, sodass in Deutschland mittlerweile jährlich etwa 3000 ECLS/ECMO-Systeme implantiert werden. Vor dem Hintergrund bislang fehlender umfassender Leitlinien bestand ein dringlicher Bedarf an der Formulierung evidenzbasierter Empfehlungen zu den zentralen Aspekten der ECLS/ECMO-Therapie.

Im Juli 2015 wurde daher die Erstellung einer S3-Leitlinie durch die Deutsche Gesellschaft für Thorax-, Herz- und Gefäßchirurgie (DGTHG) bei der zuständigen Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften e. V. (AWMF) angemeldet. In einem strukturierten Konsensusprozess mit Einbindung von Experten aus Deutschland, Österreich und der Schweiz, delegiert aus 11 AWMF-Fachgesellschaften, 5 weiteren Fachgesellschaften sowie der Patientenvertretung, entstand unter Federführung der DGTHG die Leitlinie „Einsatz der extrakorporalen Zirkulation (ECLS/ECMO) bei Herz- und Kreislaufversagen“, die im Februar 2021 publiziert wurde.

Die Leitlinie fokussiert auf klinische Aspekte der Initiierung, Fortführung, Entwöhnung und Nachsorge und adressiert hierbei auch strukturelle und ökonomische Fragestellungen. Dieser Artikel präsentiert eine Übersicht zu der Methodik und den konsentierten Empfehlungen.

Usefulness of lung ultrasound for early detection of hospital-acquired pneumonia in cardiac critically ill patients on venoarterial extracorporeal membrane oxygenation

Background

Hospital-acquired pneumonia (HAP) is the most common and severe complication in patients treated with venoarterial extracorporeal membrane oxygenation (VA ECMO) and its diagnosis remains challenging. Nothing is known about the usefulness of lung ultrasound (LUS) in early detection of HAP in patients treated with VA ECMO. Also, LUS and chest radiography were performed when HAP was suspected in cardiac critically ill adult VA ECMO presenting with acute respiratory failure. The sonographic features of HAP in VA ECMO patients were determined and we assessed the performance of the lung ultrasound simplified clinical pulmonary score (LUS-sCPIS), the sCPIS and bioclinical parameters or chest radiography alone for early diagnosis of HAP.

Results

We included 70 patients, of which 44 (63%) were independently diagnosed with HAP. LUS examination revealed that color Doppler intrapulmonary flow (P = 0.0000043) and dynamic air bronchogram (P = 0.00024) were the most frequent HAP-related signs. The LUS-sCPIS (area under the curve = 0.77) yielded significantly better results than the sCPIS (area under the curve = 0.65; P = 0.004), while leukocyte count, temperature and chest radiography were not discriminating for HAP diagnosis.

Discussion

Diagnosis of HAP is a daily challenge for the clinician managing patients on venoarterial ECMO. Lung ultrasound can be a valuable tool as the initial imaging modality for the diagnosis of pneumonia. Color Doppler intrapulmonary flow and dynamic air bronchogram appear to be particularly insightful for the diagnosis of HAP.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13613-022-01013-9.

Clinical Benefit of Extubation in Patients on Venoarterial Extracorporeal Membrane Oxygenation

OBJECTIVES

Although patients on venoarterial extracorporeal membrane oxygenation for refractory cardiogenic shock are usually supported with mechanical ventilation, it is not clear whether sedation cessation and extubation might improve outcomes.

DESIGN

Retrospective cohort study with propensity score overlap weighting analysis.

SETTING

Three ICUs in a 1,500-bed tertiary university hospital.

PATIENTS

From an overall cohort of 641 patients with venoarterial-extracorporeal membrane oxygenation support, the primary analysis was performed in 344 patients who had been successfully decannulated in order to reduce immortal time bias.

MEASUREMENTS AND MAIN RESULTS

Seventy-five patients (22%) were extubated during extracorporeal membrane oxygenation support and were subsequently decannulated alive. Forty-nine percent received noninvasive ventilation, and 25% had emergency reintubation for respiratory, neurologic, or hemodynamic reasons. Higher Simplified Acute Physiology Score II at admission (odds ratio, 0.97; 95% CI [0.95-0.99]; p = 0.008) was associated with a lower probability of extubation, whereas cannulation in cardiac surgery ICU (odds ratio, 3.14; 95% CI [1.21-8.14]; p = 0.018) was associated with an increased probability. Baseline characteristics were well balanced after propensity score overlap weighting. The number of ICU-free days within 30 days of extracorporeal membrane oxygenation decannulation was significantly higher among extubated patients compared with nonextubated patients (22 d [11-26 d] vs 18 d [7-25 d], respectively; p = 0.036). There were no differences in other outcomes including ventilator-associated pneumonia (odds ratio, 0.96; 95% CI [0.51-1.82]; p = 0.90) and all-cause mortality within 30 days of extracorporeal membrane oxygenation decannulation (5% vs 17%; hazard ratio, 0.54; 95% CI [0.19-1.59]; p = 0.27).As a secondary analysis, outcomes were compared in the overall cohort of 641 venoarterial extracorporeal membrane oxygenation-supported patients. Results were consistent with the primary analysis as extubated patients had a higher number of ICU-free days (18 d [0-24 d] vs 0 d [0-18 d], respectively; < 0.001) and a lower risk of death within 30 days of extracorporeal membrane oxygenation cannulation (hazard ratio, 0.45; 95% CI [0.29-0.71]; p = 0.001).

CONCLUSIONS

Extubation during venoarterial-extracorporeal membrane oxygenation support is safe, feasible, and associated with greater ICU-free days.

Outcomes of Venoarterial Extracorporeal Membrane Oxygenation Plus Intra-Aortic Balloon Pumping for Treatment of Acute Myocardial Infarction Complicated by Cardiogenic Shock

Background

Clinical outcomes of acute myocardial infarction complicated by cardiogenic shock remain poor with high in‐hospital mortality. Veno‐arterial extracorporeal membrane oxygenation (VA‐ECMO) has been widely used for patients with acute myocardial infarction complicated by cardiogenic shock refractory to conservative therapy, which is likely fatal without mechanical circulatory support. However, whether additional intra‐aortic balloon pumping (IABP) use during VA‐ECMO support improves clinical outcomes remains controversial. This study sought to investigate prognostic impact of the combined VA‐ECMO plus IABP treatment compared with VA‐ECMO alone.

Methods and Results

From the nationwide Japanese administrative case‐mix Diagnostic Procedure Combination (DPC), the JROAD (Japanese Registry of All Cardiac and Vascular Diseases)–DPC, we identified 3815 patients with acute myocardial infarction complicated by cardiogenic shock who underwent primary percutaneous coronary intervention and managed with VA‐ECMO. Of these, 2964 patients (77.7%) were managed with IABP (VA‐ECMO plus IABP), whereas 851 (22.3%) were managed without IABP (VA‐ECMO alone). We compared in‐hospital, 7‐day, and 30‐day mortality between the VA‐ECMO plus IABP versus the VA‐ECMO alone support. Patients managed with VA‐ECMO plus IABP demonstrated significantly lower in‐hospital, 7‐day, and 30‐day mortality than those managed with VA‐ECMO alone (adjusted odds ratios [95% CI] of 0.47 [95% CI, 0.38–0.59], 0.41 [95% CI, 0.33–0.51], and 0.30 [95% CI, 0.25–0.37], respectively). The findings were consistent in the propensity matching and inverse probability of treatment‐weighting models.

Conclusions

This large‐scale, nationwide study demonstrated that the combination of VA‐ECMO plus IABP support was associated with significantly lower mortality compared with VA‐ECMO support alone in patients presenting with acute myocardial infarction complicated by cardiogenic shock who underwent primary percutaneous coronary intervention.

Perioperative temporary mechanical circulatory support with Impella in cardiac surgery patients

BACKGROUND

The benefits of perioperative mechanical circulatory support (MCS) in cardiac surgery patients are still uncertain. This study aims to review early outcomes of perioperative temporary MCS using the Impella device in cardiac surgery patients.

METHODS

Retrospective, single-center analysis in cardiac surgery patients presenting with cardiogenic shock (CS) in whom Impella was used for perioperative temporary MCS, either as single device therapy or as left ventricular (LV) venting strategy for concomitant extracorporeal membrane oxygenation (ECPELLA). Study outcomes were 30-day mortality and occurrence of complication composite outcome.

RESULTS

Between 2016 and 2019, a total of 33 consecutive patients were supported with Impella (single-device therapy in 19 [57.6%] patients and ECPELLA in 14 [42.4%] patients). The 30-day mortality of Impella-alone and ECPELLA groups was 15.8% and 50.0% (P=0.03). The 30-day mortality according to pre-, intra-, and postoperative implantation was 12.5%, 60.0%, and 28.6% (P=0.04), and it was significantly lower in those patients in whom a left ventricular assist device was implanted in comparison to all other surgical procedures (P<0.01). The complication composite outcome occurred more frequently after axillary implantation compared to femoral Impella (P=0.05) due to higher stroke rates (P=0.03). Bleeding requiring surgical re-exploration was more frequent in the ECPELLA than in the Impella-alone group (1 [3.0%] vs. 5 [15.1%]; P=0.03).

CONCLUSIONS

Temporary MCS with Impella is associated with high complication and mortality rates. However, preoperative use of Impella as single-device temporary MCS is associated with lower mortality rates and is a reasonable alternative as a bridge-to-decision strategy for acutely decompensated patients.

Outcome of Extracorporeal Membrane Oxygenation Combined with Intraaortic Balloon Pump Hemodynamic Support during the Percutaneous Coronary Intervention Process for Patients with Cardiac Shock Complicating Acute Myocardial Infarction

We evaluate the effect of extracorporeal membrane oxygenation combined with intraaortic balloon pump mechanical circulatory support for patients with cardiogenic shock complicating acute myocardial infarction during the PCI process. Extracorporeal membrane oxygenation combined with intraaortic balloon pump hemodynamic support during the percutaneous coronary intervention process for patients with cardiac shock complicating acute myocardial infarction might play a complementary role. Yet, evidence of application of both devices at the same time remains unclear. Patients with cardiogenic shock complicating myocardial infarction who underwent PCI in our hospital from January 2015 to January 2018 were screened. Those who were under hemodynamic support of extracorporeal membrane oxygenation combined with intraaortic balloon pump were enrolled as the ECMO&IABP group, and the patients only under support of intraaortic balloon pump were enrolled as the IABP group. The differences of clinical prognosis between the two groups were compared. A total of 39 patients were enrolled into the study: 10 were in the ECMO&IABP group and 29 in the IABP group. Compared with the IABP group, more patients were complicated with old myocardial infarction (5/10 vs. 2/29, p=0.002), more patients were diagnosed as non-ST elevated myocardial infarction (8/10 vs. 11/29, p=0.002) and left ventricular ejecting fraction was lower (41.1 ± 9.86 vs. 48.55 ± 8.86, p=0.03) in the ECMO&IABP group. Mechanical complications were higher in the ECMO&IABP group (5/10 vs. 5/29, p=0.048), The survive rate in the ECMO&IABP group is higher than that in the IABP group (90.00% vs. 47.83%, p=0.042) at one-year follow-up. Compared with only IABP, ECMO combined with IABP hemodynamic support during the PCI process for patients with cardiogenic shock complicating acute myocardial infarction enjoys better mortality outcome.

Mortality in cardiogenic shock patients receiving mechanical circulatory support: a network meta-analysis

Objective

Mechanical circulatory support (MCS) devices are widely used for cardiogenic shock (CS). This network meta-analysis aims to evaluate which MCS strategy offers advantages.

Methods

A systemic search of PubMed, EMBASE, and the Cochrane Central Register of Controlled Trials was performed. Studies included double-blind, randomized controlled, and observational trials, with 30-day follow-ups. Paired independent researchers conducted the screening, data extraction, quality assessment, and consistency and heterogeneity assessment.

Results

We included 39 studies (1 report). No significant difference in 30-day mortality was noted between venoarterial extracorporeal membrane oxygenation (VA-ECMO) and VA-ECMO plus Impella, Impella, and medical therapy. According to the surface under the cumulative ranking curve, the optimal ranking of the interventions was surgical venting plus VA-ECMO, medical therapy, VA-ECMO plus Impella, intra-aortic balloon pump (IABP), Impella, Tandem Heart, VA-ECMO, and Impella plus IABP. Regarding in-hospital mortality and 30-day mortality, the forest plot showed low heterogeneity. The results of the node-splitting approach showed that direct and indirect comparisons had a relatively high consistency.

Conclusions

IABP more effectively reduce the incidence of 30-day mortality compared with VA-ECMO and Impella for the treatment of CS.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12872-022-02493-0.

Use of extracorporeal circulation (ECLS/ECMO) for cardiac and circulatory failure -A clinical practice Guideline Level 3

Aims Worldwide applications of extracorporeal circulation for mechanical support in cardiac and circulatory failure, which are referred to as extracorporeal life support (ECLS) or veno‐arterial extracorporeal membrane oxygenation (va‐ECMO), have dramatically increased over the past decade. In spite of the expanding use and the immense medical as well as socio‐economic impact of this therapeutic approach, there has been a lack of interdisciplinary recommendations considering the best available evidence for ECLS treatment.

Methods and Results In a multiprofessional, interdisciplinary scientific effort of all scientific societies involved in the treatment of patients with acute cardiac and circulatory failure, the first evidence‐ and expert consensus‐based guideline (level S3) on ECLS/ECMO therapy was developed in a structured approach under regulations of the AWMF (Association of the Scientific Medical Societies in Germany) and under use of GRADE (Grading of Recommendations Assessment, Development and Evaluation) criteria. This article presents all recommendations created by the expert panel, addressing a multitude of aspects for ECLS initiation, continuation, weaning and aftercare as well as structural and personnel requirements.

Conclusions This first evidence‐ and expert consensus‐based guideline (level S3) on ECLS/ECMO therapy should be used to apply the best available care nationwide. Beyond clinical practice advice, remaining important research aspects for future scientific efforts are formulated.

Temporary mechanical circulatory support in cardiogenic shock

Cardiogenic shock (CS) represents one of the foremost concerns in the field of acute cardiovascular medicine. Despite major advances in treatment, mortality of CS remains high. International societies recommend the development of expert CS centers with standardized protocols for CS diagnosis and treatment. In these terms, devices for temporary mechanical circulatory support (MCS) can be used to support the compromised circulation and could improve clinical outcome in selected patient populations presenting with CS. In the past years, we have witnessed an immense increase in the utilization of MCS devices to improve the clinical problem of low cardiac output. Although some treatment guidelines include the use of temporary MCS up to now no large randomized controlled trial confirmed a reduction in mortality in CS patients after MCS and additional research evidence is necessary to fully comprehend the clinical value of MCS in CS. In this article, we provide an overview of the most important diagnostic and therapeutic modalities in CS with the main focus on contemporary MCS devices, current state of art and scientific evidence for its clinical application and outline directions of future research efforts.

Cardiogenic shock in Taiwan from 2003 to 2017 (CSiT-15 study)

BACKGROUND

This study investigated temporal trends in the treatment and mortality of patients with cardiogenic shock (CS) in Taiwan in relation to acute myocardial infarction (AMI) accreditation implemented in 2009 and the unavailability of percutaneous ventricular assist devices.

METHODS

Data of patients diagnosed as having CS between January 2003 and December 2017 were collected from Taiwan's National Health Insurance Research Database. Each case was followed from the date of emergency department arrival or hospital admission for the first incident associated with a CS diagnosis up to a 1-year interval. Measurements included demographics, comorbidities, treatment, mortality, and medical costs. Using an interrupted time-series (ITS) design with multi-level mixed-effects logistic regression model, we assessed the impact of AMI accreditation implementation on the mortality of patients with AMI and CS overall and stratified by the hospital levels.

RESULTS

In total, 64 049 patients with CS (mean age:70 years; 62% men) were identified. The incidence rate per 10⁵ person-years increased from 17 in 2003 to 25 in 2010 and plateaued thereafter. Average inpatient costs increased from 159 125 points in 2003 to 240 993 points in 2017, indicating a 1.5-fold increase. The intra-aortic balloon pump application rate was approximately 22-25% after 2010 (p = 0.093). Overall, in-hospital, 30-day, and 1-year mortality declined from 60.3%, 63.0%, and 69.3% in 2003 to 47.9%, 50.8% and 59.8% in 2017, respectively. The decline in mortality was more apparent in patients with AMI-CS than in patients with non-AMI-CS. The ITS estimation revealed a 2% lower in-hospital mortality in patients with AMI-CS treated in district hospitals after the AMI accreditation had been implemented for 2 years.

CONCLUSIONS

In Taiwan, the burden of CS has consistently increased due to high patient complexity, advanced therapies, and stable incidence. Mortality declined over time, particularly in patients with AMI-CS, which may be attributable to advancements in AMI therapies and this quality-improving policy.

Extracorporeal Life Support for Cardiac Arrest and Cardiogenic Shock

The rising incidence and recognition of cardiogenic shock has led to an increase in the use of veno-arterial extracorporeal membrane oxygenation (VA-ECMO). As clinical experience with this therapy has increased, there has also been a rapid growth in the body of observational and randomized data describing the clinical and logistical considerations required to institute a VA-ECMO program with successful clinical outcomes. The aim of this review is to summarize this contemporary data in the context of four key themes that pertain to VA-ECMO programs: the principles of patient selection; basic hemodynamic and technical principles underlying VA-ECMO; contraindications to VA-ECMO therapy; and common complications and intensive care considerations that are encountered in the setting of VA-ECMO therapy.

Prognostic significance of intra-aortic balloon pumping support in patients with acute myocardial infarction and veno-arterial extracorporeal membrane oxygenation therapy

BACKGROUND

The prognostic significance of combining intra-aortic balloon pumping (IABP) with extracorporeal membrane oxygenation (ECMO) for acute myocardial infarction (AMI) patients is still unclear. We investigated whether combining IABP with veno-arterial (VA)-ECMO is associated with a lower risk of short-term mortality.

METHODS

Among 12,093 AMI cases enrolled in the Osaka Acute Coronary Insufficiency Study (OACIS), we identified 519 who were administered VA-ECMO during hospitalization. Among these, 459 received IABP support (IABP group) and 60 cases did not (no-IABP group). The primary endpoint was 30-day all-cause death; the secondary endpoint was major bleeding. Logistic regression analysis using original data was conducted. We also established weighted logistic regression models with inverse probability of treatment weighting (IPTW).

RESULTS

Logistic regression analysis revealed that IABP use was significantly associated with a reduced risk of 30-day death in the original data [odds ratio (OR) 0.504, 95% confidence interval (CI) 0.282-0.901, p = 0.021]. After IPTW-adjustment for clinically relevant covariates with the use of IABP, patients receiving VA-ECMO with IABP had a lower risk of 30-day death (OR 0.816, 95% CI 0.746-0.892, p < 0.001) compared to those without IABP. The incidence of major bleeding was comparable between the groups (IABP 29.0% vs. non-IABP 21.7%, p=0.302). However, the risk of major bleeding was higher in the IABP group after IPTW-adjustment (OR 1.092, 95% CI 1.008-1.184, p=0.032).

CONCLUSIONS

IABP support for AMI patients with VA-ECMO was significantly associated with reduced risk of short-term mortality, suggesting that the addition of IABP support might contribute to improved survival in AMI patients requiring VA-ECMO.

[Use of extracorporeal circulation (ECLS/ECMO) for cardiac and circulatory failure : Short version of the S3 guideline]

In Germany, a remarkable increase regarding the usage of extracorporeal membrane oxygenation (ECMO) and extracorporeal life support (ECLS) systems has been observed in recent years with approximately 3000 ECLS/ECMO implantations annually since 2015. Despite the widespread use of ECLS/ECMO, evidence-based recommendations or guidelines are still lacking regarding indications, contraindications, limitations and management of ECMO/ECLS patients. Therefore in 2015, the German Society of Thoracic and Cardiovascular Surgery (GSTCVS) registered the multidisciplinary S3 guideline "Use of extracorporeal circulation (ECLS/ECMO) for cardiac and circulatory failure" to develop evidence-based recommendations for ECMO/ECLS systems according to the requirements of the Association of the Scientific Medical Societies in Germany (AWMF). Although the clinical application of ECMO/ECLS represents the main focus, the presented guideline also addresses structural and economic issues. Experts from 17 German, Austrian and Swiss scientific societies and a patients' organization, guided by the GSTCVS, completed the project in February 2021. In this report, we present a summary of the methodological concept and tables displaying the recommendations for each chapter of the guideline.