Abstract Introduction Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is a life-saving mechanical circulatory support (MCS) modality for patients with refractory cardiogenic shock (CS). However, despite its benefits, VA-ECMO increases left ventricular (LV) afterload, which can lead to pulmonary edema and LV distension. Recently, the transcatheter LV assist device Impella has been introduced, and the potential benefits of the concomitant use of VA-ECMO and Impella (ECPELLA) have been recognized. However, due to an increased risk of complications, the utility of ECPELLA remains controversial and unsettled. Objective This single-center cohort study aimed to evaluate the impact of ECPELLA compared to VA-ECMO with or without intra-aortic balloon pump (IABP) in patients with refractory CS, including those with cardiac arrest, who received VA-ECMO treatment. Methods We retrospectively reviewed 353 consecutive patients who underwent VA-ECMO treatment at our institution between January 2012 and December 2024. A total of 27 patients were excluded, including 22 requiring VA-ECMO for cardiopulmonary bypass weaning and 5 for backup during high-risk transcatheter aortic valve implantation. The remaining patients were divided into two groups: the ECPELLA group (n=134) and the VA-ECMO with or without IABP group (n=197). We performed propensity score matching in a 1:1 ratio using age, male sex, acute coronary syndrome, out-of-hospital and in-hospital cardiac arrest, and extracorporeal cardiopulmonary resuscitation as dependent variables. Hemodynamic data, safety outcomes, and 30-day mortality were assessed. Results After propensity score matching, 116 patients in each group were included in the final analysis. No significant differences were observed in adjusted variables and comorbidities, except for a significantly higher prevalence of renal impairment (eGFR 60 mL/min/1.73 m²) in the VA-ECMO group. In the VA-ECMO group, 62% of patients received concomitant IABP support. During the first 72 hours following VA-ECMO initiation, the ECPELLA group received significantly higher total MCS flow and required lower catecholamine administration than the VA-ECMO group. Regarding safety outcomes, the ECPELLA group had a significantly higher incidence of bleeding, embolic stroke, sepsis, hemolysis, and limb ischemia compared to the VA-ECMO with IABP group. Kaplan-Meier analysis demonstrated that 30-day survival rates were significantly higher in the ECPELLA group than in the VA-ECMO group (p 0.001). Multivariate Cox proportional hazard analysis identified age (hazard ratio HR: 1.19 per 10-year increase; 95% confidence interval CI: 1.06–1.34, p = 0.004), lactate level at the emergency room (HR: 1.06; 95% CI: 1.03–1.09, p 0.001), and ECPELLA (HR: 0.48; 95% CI: 0.35–0.66, p 0.001) as independent predictors of 30-day mortality. Conclusion ECPELLA was associated with improved short-term survival in patients with refractory CS requiring VA-ECMO.Figure1 Figure2
Inamori et al. (Sat,) studied this question.
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