ID:53 FC-D11-6 Impella versus Intra-Aortic Balloon Pump for Left Ventricular Unloading During VA-ECMO: A Systematic Review and Meta-Analysis

Background: Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) for cardiogenic shock increases left ventricular (LV) afterload, potentially leading to LV distension and pulmonary congestion. While Impella and intra-aortic balloon pump (IABP) are commonly used for LV unloading, their comparative clinical efficacy remains unclear. Methods: A systematic literature search was conducted for retrospective cohort studies published through December 2025. A total of 12,667 patients were analyzed, comprising 5,392 patients in the Impella group and 7,275 patients in the IABP group. The primary outcome was in-hospital mortality. Secondary outcomes included bleeding, vascular complications, renal replacement therapy (RRT) requirement, ischemic stroke, duration of VA-ECMO support, and length of hospital stay. Results: Nine retrospective studies were included. Pooled analysis demonstrated no significant difference in in-hospital mortality between the Impella and IABP groups (RR = 1.10; 95% CI 0.96–1.25; P = 0.16). Regarding secondary outcomes, Impella was associated with a significantly shorter duration of VA-ECMO support (SMD = –0.50; P = 0.04) compared to IABP. However, the Impella group had a significantly higher requirement for RRT (RR = 1.36; P < 0.00001). No significant differences were found in the risks of bleeding, vascular complications, ischemic stroke, or total length of hospital stay between the two strategies. Conclusion: Both Impella and IABP provide similar survival benefits as LV unloading strategies in VA-ECMO patients. Impella may facilitate earlier ECMO weaning but is associated with an increased need for renal support. Device selection should be tailored to individual patient profiles and institutional expertise.