Use of temporary mechanical circulatory support: results of the BIWAC registry

Introduction Temporary mechanical circulatory support (MCS) is increasingly utilised in patients in cardiogenic shock (CS), cardiac arrest, or those undergoing high-risk cardiac interventions. This study aims to assess the current use of MCS in Belgium. Methods From January 2022 to December 2024, patients receiving MCS were prospectively enrolled in four tertiary care centers. MCS modalities included intra-aortic balloon pump (IABP), veno-arterial extracorporeal membrane oxygenation (VA-ECMO) and percutaneous left ventricular assist device (pLVAD). Results During this study period, 254 patients were included in the registry. VA-ECMO was used in 49.6% of patients, IABP alone in 47.6% of patients, pLVAD in 2.8% of patients. In 31.7% of patients, VA-ECMO was combined with IABP or pLVAD. In one patient VA-ECMO was combined with a right ventricular assist device. The MCS indication was cardiogenic shock in 42.9%, extracorporeal cardiopulmonary resuscitation (eCPR) in 19.3% and postcardiotomy in 26%. Main indications for VA-ECMO were eCPR and CS. Main indication for IABP and pLVAD alone was CS, mostly caused by acute myocardial infarction (AMICS), respectively in 70.5% and 50% of patients in CS (figure 1). Patients supported by IABP were older compared to VA-ECMO patients (p < 0.001). At MCS initiation, patients with VA-ECMO (eCPR excluded) exhibited significantly higher lactate levels and lower pH levels compared to those with IABP alone (p<0.001). Cardiogenic shock SCAI D or E was present in 68% of IABP patients, in 75% of pLVAD patients and in 97% of VA-ECMO patients. In VA-ECMO supported patients, the most frequent complications were acute kidney injury (43.7%), major bleeding (19%) and limb ischemia (13.5%). Of patients supported by IABP, 41.3% developed acute kidney injury, 2.5% major bleeding and 2.5% limb ischemia. In pLVAD patients, 42.8% developed hemolysis, 28.6% acute kidney injury, 14.3% major bleeding, and 14.3% limb ischemia. In-hospital mortality was 34.7% on IABP (46% in AMICS) and 59.5% on VA-ECMO (69.4% in eCPR, 81.2% in AMICS and 42.9% postcardiotomy) (table 1). In survivors, the median MCS duration was 5 days (IQR 3-8 days), and the median ICU length of stay was 14 days (IQR 7-27 days). Patients left the ICU with a good neurological outcome (Cerebral Performance Category score 1 or 2) in 71.2%. Neurological outcome was good in 64.3 % of patients who survived eCPR. Conclusion Despite current ESC guidelines, IABP remains widely used for cardiogenic shock, particularly in AMICS. VA-ECMO is primarily utilized for eCPR and severe CS (SCAI D and E). Patients receiving VA-ECMO have higher mortality rates compared to those with IABP or pLVAD. The low utilization of pLVAD may be attributed to financial constraints and reimbursement policies. IABP is mainly used in patients who might not have been considered for other devices based on patient’s profile (older, more comorbidities) or who present with less severe shock.