Timing of Active Left Ventricular Unloading in Patients on Venoarterial Extracorporeal Membrane Oxygenation Therapy

Schrage, Benedikt; Sundermeyer, Jonas; Blankenberg, Stefan; Colson, P; Eckner, Dennis; Eden, Matthias; Eitel, Ingo; Frank, Derk; Frey, Norbert; Graf, Tobias; Kirchhof, Paulus; Kupka, Danny; Landmesser, Ulf; Linke, Axel; Majunke, Nicolas; Maniuc, Octavian; Mierke, Johannes; Möbius‐Winkler, Sven; Morrow, David A.; Mourad, Marc; Nordbeck, Peter; Orban, Martin; Pappalardo, Federico; Patel, Sandeep M.; Pauschinger, Matthias; Pazzanese, Vittorio; Radakovic, D.; Schulze, P. Christian; Scherer, Clemens; Schwinger, Robert H. G.; Skurk, Carsten; Thiele, Holger; Varshney, Anubodh; Wechsler, Lukas; Westermann, Dirk

doi:10.1016/j.jchf.2022.11.005

Cited by 46 publications

(51 citation statements)

References 18 publications

Supporting

Mentioning

Contrasting

Unclassified

Order By: Relevance

“…Lastly, patients treated with a prophylactic LV decompression strategy may be less likely to develop stroke-inducing thrombi than patients with VA-ECMO-associated blood stasis in the aortic root and potential thrombus formation [ 25 , 26 ]. Of note, no difference in vascular complication rates between these two groups was found, and the results were comparable to those of previous studies [ 9 , 27 , 28 , 29 , 30 ]. Prospective randomized trials are required to confirm these promising results.…”

Section: Discussionsupporting

confidence: 89%

Left Ventricular Unloading in Patients on Venoarterial Extracorporeal Membrane Oxygenation Therapy in Cardiogenic Shock: Prophylactic Versus Bail-Out Strategy

Radakovic

Zittermann

Rojas

et al. 2023

Life

Self Cite

View full text Add to dashboard Cite

Background: The benefit of prophylactic left ventricular (LV) unloading during venoarterial extracorporeal membrane oxygenation (VA-ECMO) in selected patients at risk of developing LV distension remains unclear. Methods: We enrolled 136 patients treated with Impella pump decompression during VA-ECMO therapy for refractory cardiogenic shock. Patients were stratified by specific indication for LV unloading in the prophylactic vs. bail-out group. The bail-out unloading strategy was utilized to treat LV distension in VA-ECMO afterload-associated complications. The primary endpoint was all-cause 30-day mortality after VA-ECMO implantation. The secondary endpoint was successful myocardial recovery, transition to durable mechanical circulatory support (MCS), or heart transplantation. Results: After propensity score matching, prophylactic unloading was associated with a significantly lower 30-day mortality risk (risk ratio 0.38, 95% confidence interval 0.23–0.62, and p < 0.001) and a higher probability of myocardial recovery (risk ratio 2.9, 95% confidence interval 1.48–4.54, and p = 0.001) compared with the bail-out strategy. Heart transplantation or durable MCS did not differ significantly between groups. Conclusions: Prophylactic unloading compared with the bail-out strategy may improve clinical outcomes in selected patients on VA-ECMO. Nevertheless, randomized trials are needed to validate these results.

show abstract

Section: Discussionsupporting

confidence: 89%

Left Ventricular Unloading in Patients on Venoarterial Extracorporeal Membrane Oxygenation Therapy in Cardiogenic Shock: Prophylactic Versus Bail-Out Strategy

Radakovic

Zittermann

Rojas

et al. 2023

Life

Self Cite

View full text Add to dashboard Cite

show abstract

“…Noticeably, the median time from arrest initiation to ECMO flow onset was 74 min (IQR: 63-87) in the INCEPTION study, whereas it was 58 min (IQR: 43-70) in the Prague trial. Similarly, the median (IQR) cannulation procedure time was notably shorter in the Prague Study compared to the INCEPTION trial (12 (9-15) versus 20 (11)(12)(13)(14)(15)(16)(17)(18)(19)(20)(21)(22)(23)(24)(25) minutes). The INCEPTION study underscored the intricacies of implementing ECPR in real-world scenarios, even in highly developed countries, emphasizing that outcomes achieved in specialized centers might not be universally reproducible.…”

Section: Ecmo On Cardiopulmonary Resuscitation In Refractory Out-of-h...mentioning

confidence: 95%

“…An evaluation involving 421 patients experiencing cardiogenic shock and treated with VA-ECMO and active left ventricle (LV) unloading across 18 tertiary care centers in four countries aimed to assess the relationship between the timing of active LV unloading through Impella and VA-ECMO implantation and patient outcomes within this group. 15 Early LV unloading was characterized by Impella implantation within 2 h after VA-ECMO initiation, while delayed LV unloading occurred between 2 and 24 h post-VA-ECMO onset. Nearly three-quarters of the studied population underwent early active LV unloading.…”

Section: Va Ecmo For Refractory Cardiogenic Shockmentioning

confidence: 99%

What’s new in adult extracorporeal membrane oxygenation in 2022–2023? Insights from the EuroELSO congress 2023

Schmidt

2023

Perfusion

View full text Add to dashboard Cite

“…15 In addition, a recent retrospective multicentre registry showed that early LV unloading (defined by implantation within 2 h after VA-ECMO) was associated with lower 30-day mortality (hazard ratio 0.64, 95% CI 0.46-0.88) without increased complication rates compared with delayed LV unloading. 23 However, these aforementioned studies were observational and the possibility of selection bias could not be excluded. Thus, controversy remains regarding whether early LV unloading might be beneficial in patients receiving VA-ECMO.…”

Section: Timing Of Left Ventricular Unloadingmentioning

confidence: 99%

Early left atrial venting versus conventional treatment for left ventricular decompression during venoarterial extracorporeal membrane oxygenation support: The EVOLVE‐ECMO randomized clinical trial

Park,

Yang,

Ahn

et al. 2023

European J of Heart Fail

View full text Add to dashboard Cite

AimsFew studies have reported data on the optimal timing of left ventricular (LV) unloading during venoarterial extracorporeal membrane oxygenation (VA‐ECMO) for cardiac arrest or shock. This study evaluated the feasibility of an early LV unloading strategy compared with a conventional strategy in VA‐ECMO.Methods and resultsBetween December 2018 and August 2022, 60 patients at two institutions were randomized in a 1:1 ratio to receive early (n = 30) or conventional (n = 30) LV unloading strategies. The early LV unloading strategy was defined as LV unloading performed at the time of VA‐ECMO insertion. LV unloading was performed using a percutaneous transseptal left atrial cannulation via the femoral vein incorporated into the ECMO venous circuit. The early and conventional LV unloading groups included 29 (96.7%) and 23 (76.7%) patients, respectively (median time from VA‐ECMO insertion to LV unloading: 48.4 h, interquartile range 47.8–96.5 h). The groups showed no significant differences in the rate of VA‐ECMO weaning as the primary endpoint (70.0% vs. 76.7%; relative risk 0.91; 95% confidence interval 0.67–1.24; p = 0.386) and survival to discharge (53.3% vs. 50.0%, p = 0.796). However, the pulmonary congestion score index at 48 h after LV unloading was significantly improved only in the early LV unloading group (2.0 ± 0.7 vs. 1.7 ± 0.6 at baseline vs. at 48 h; p = 0.008).ConclusionsCompared with the conventional approach, early LV unloading did not improve the VA‐ECMO weaning rate, despite the rapid improvement in pulmonary congestion. Therefore, the results of this study do not support the application of this strategy after VA‐ECMO insertion.

show abstract

Timing of Active Left Ventricular Unloading in Patients on Venoarterial Extracorporeal Membrane Oxygenation Therapy

Cited by 46 publications

References 18 publications

Left Ventricular Unloading in Patients on Venoarterial Extracorporeal Membrane Oxygenation Therapy in Cardiogenic Shock: Prophylactic Versus Bail-Out Strategy

Left Ventricular Unloading in Patients on Venoarterial Extracorporeal Membrane Oxygenation Therapy in Cardiogenic Shock: Prophylactic Versus Bail-Out Strategy

What’s new in adult extracorporeal membrane oxygenation in 2022–2023? Insights from the EuroELSO congress 2023

Early left atrial venting versus conventional treatment for left ventricular decompression during venoarterial extracorporeal membrane oxygenation support: The EVOLVE‐ECMO randomized clinical trial

Contact Info

Product

Resources

About