Impella Versus Extracorporeal Membrane Oxygenation in Cardiogenic Shock: A Systematic Review and Meta-Analysis

Abstract

Background: Cardiogenic shock (CS) carries high mortality. The roles of specific mechanical circulatory support (MCS) systems are unclear. We compared the clinical outcomes of Impella versus extracorporal membrane oxygenation (ECMO) in patients with CS. Methods: This is a systematic review and meta-analysis that was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta Analyses guidelines. We searched PubMed, Cochrane Central Register, Embase, Web of Science, Google Scholar, and ClinicalTrials.gov (inception through May 10, 2022) for studies comparing the outcomes of Impella versus ECMO in CS. We used random-effects models to calculate risk ratios (RRs) with 95% confidence interval (CIs). End points included in-hospital, 30-day, and 12-month all-cause mortality, successful weaning from MCS, bridge to transplant, all reported bleeding, stroke, and acute kidney injury. Results: A total of 10 studies consisting of 1,827 CS patients treated with MCS were included in the analysis. The risk of in-hospital all-cause mortality was significantly lower with Impella compared with ECMO (RR, 0.80; 95% CI, 0.65–1.00; P = 0.05), whereas there was no statistically significant difference in 30-day (RR, 0.97, 95% CI, 0.82–1.16; P = 0.77) and 12-month mortality (RR, 0.90; 95% CI, 0.74–1.11; P = 0.32). There were no significant differences between the two groups in terms of successful weaning (RR, 0.97; 95% CI, 0.81–1.15; P = 0.70) and bridging to transplant (RR, 0.88; 95% CI, 0.58–1.35; P = 0.56). There was less risk of bleeding and stroke in the Impella group compared with the ECMO group. Conclusions: In patients with CS, the use of Impella is associated with lower rates of in-hospital mortality, bleeding, and stroke than ECMO. Future randomized studies with adequate sample sizes are needed to confirm these findings.

Impella and venoarterial extracorporeal membrane oxygenation in cardiogenic shock complicating acute myocardial infarction

“…This might be due to the unselected, real‐world, national, registry‐based character of this study 17 . Like our study, higher in‐hospital mortality in VA‐ECMO patients compared to Impella patients has been reported previously 16–18 . However, as underscored by the recent publication of Almarzooq et al ., 19 the differences in clinical outcomes between Impella and VA‐ECMO in this observational data analysis must be interpreted in the setting of possible unmeasured and unadjusted confounders in patient and institutional characteristics.…”

“…17 Like our study, higher in-hospital mortality in VA-ECMO patients compared to Impella patients has been reported previously. [16][17][18] However, as underscored by the recent publication of Almarzooq et al, 19 the differences in clinical outcomes between Impella and VA-ECMO in this observational data analysis must be interpreted in the setting of possible unmeasured and unadjusted confounders in patient and institutional characteristics. For instance due to physicians' preferences and device availability, but also depending on cardiogenic shock severity (according to the SCAI classification), risk modifiers, and cardiogenic shock phenotype.…”

“…However, considering the included studies and the quickly evolving MCS landscape, these meta-analyses may not resemble the most current practice. [15][16][17][18] In addition, these meta-analyses did not report on the length of stay and healthcare costs.…”

“…All of them report significantly lower in‐hospital mortality for patients with an Impella versus VA‐ECMO. However, considering the included studies and the quickly evolving MCS landscape, these meta‐analyses may not resemble the most current practice 15–18 . In addition, these meta‐analyses did not report on the length of stay and healthcare costs.…”

New Insights into Mortality-Related Risk Factors in Infective Endocarditis: Results from the Brandenburg State Endocarditis Register

“…Furthermore, reduction or avoidance of potentially nephrotoxic drugs can help. Moreover, low cardiac output can be at least partly managed by prompt use of ECLS and Impella-Pump (ECMELLA) (26). Cardiopulmonary bypass (CPB) time increased with the complexity of the procedure and thus, resulted in an increased mortality.…”