Key result
Mechanical unloading during VA-ECMO was associated with lower in-hospital mortality (aOR 0.84; 95% CI 0.77-0.92; P<0.001) compared to no unloading, despite increased bleeding and hemolysis.
Why the study?
The net clinical benefit of mechanical left ventricular unloading with IABP or pVAD during VA-ECMO remains uncertain due to potential complications and unclear impact on outcomes.
Does mechanical left ventricular unloading reduce in-hospital mortality in adult patients undergoing peripheral VA-ECMO?
Cohort (n=12,734)
Yes
Does mechanical left ventricular unloading reduce in-hospital mortality in adult patients undergoing peripheral VA-ECMO?
In adults undergoing VA-ECMO, mechanical left ventricular unloading is associated with improved in-hospital survival despite an increased risk of bleeding and hemolysis.
Venoarterial extracorporeal membrane oxygenation (VA-ECMO) increases left ventricular (LV) afterload, potentially provoking LV distention and impairing recovery. LV mechanical unloading (MU) with intra-aortic balloon pump (IABP) or percutaneous ventricular assist device (pVAD) can prevent LV distension, potentially at the risk of more complications, and net clinical benefit remains uncertain. This study aims to determine the association between MU and outcomes for patients undergoing VA-ECMO. The authors queried the Extracorporeal Life Support Organization registry for adults receiving peripheral VA-ECMO from 2010 to 2019 and stratified them by MU with IABP or pVAD. The primary outcome was in-hospital mortality; secondary outcomes included on-support mortality and complications during VA-ECMO. Among 12,734 VA-ECMO patients, 3,399 (26.7%) received MU: 2,782 (82.9%) IABP and 580 (17.1%) pVAD. MU patients were older (age 56.3 vs 52.7 years) and, before extracorporeal membrane oxygenation, more often required >2 vasopressors (41.7% vs 27.2%) and had respiratory (21.1% vs 15.9%), renal (24.6% vs 15.8%), and liver failure (4.4% vs 3.1%) (all P < 0.001). MU patients had lower in-hospital mortality (56.6% vs 59.3%, P = 0.006), which persisted in multivariable modeling (adjusted OR [aOR]: 0.84; 95% CI: 0.77–0.92; P < 0.001). MU was associated with more cannula site bleeding (aOR: 1.25; 95% CI: 1.11–1.40; P < 0.001) and hemolysis (aOR: 1.27; 95% CI: 1.03–1.57; P = 0.02). Compared to pVAD, MU patients with IABP had similar mortality (aOR: 0.80; 95% CI: 0.64–1.01; P = 0.06) and less medical bleeding (aOR: 0.45; 95% CI: 0.31–0.64; P < 0.001), cannula site bleeding (aOR: 0.72; 95% CI: 0.54–0.96; P = 0.03), and renal injury (aOR: 0.78; 95% CI: 0.62–0.98; P = 0.03). Among adults receiving VA-ECMO, MU was associated with lower in-hospital mortality despite increased complications including hemolysis and cannulation site bleeding. Compared to pVAD, MU with IABP was associated with similar mortality and lower complication rates.
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Grandin et al. (2022) conducted a cohort in Venoarterial extracorporeal membrane oxygenation (VA-ECMO) (n=12,734). Mechanical unloading with IABP or pVAD vs. No mechanical unloading was evaluated on In-hospital mortality (aOR 0.84, 95% CI 0.77-0.92, p=<0.001). Mechanical unloading during VA-ECMO was associated with lower in-hospital mortality (aOR 0.84; 95% CI 0.77-0.92; P<0.001) compared to no unloading, despite increased bleeding and hemolysis.
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