Abstract Background Extracorporeal cardiopulmonary resuscitation (E-CPR) is used for cardiac arrest (CA) when conventional CPR fails. Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) provides systemic perfusion but increases left ventricular (LV) afterload. The Impella device facilitates LV unloading, making this combined approach (ECPELLA) potentially beneficial for E-CPR patients with biventricular failure. However, in the era of ECPELLA, the criteria for patient selection and risk stratification in E-CPR remain unclear. Purpose This study evaluated short-term prognosis and associated factors in E-CPR patients managed with ECPELLA. Additionally, we explored whether specific parameters could predict survival. Methods The UNLOADERS-PVAD registry is a multicenter observational study in Japan, including data from three leading Impella centers. In this cohort, 501 patients received Impella support between April 2018 and December 2023. Among them, 188 patients underwent E-CPR with ECPELLA. Patients were divided into two groups: a 30-day survival group (n = 87) and a non-survival group (n = 101). To assess factors influencing prognosis, we analyzed patient characteristics, including age, sex, baseline comorbidities, cause of cardiac arrest, location of CA (in-hospital or out-of-hospital CA), and collapse-to-VA-ECMO initiation time (CTET), along with laboratory findings and post-VA-ECMO hemodynamic parameters. Prognostic scores, including APACHE II, SAPS II, and SAVE, were also calculated. Results The 30-day survival rate was 46%, with 24% achieving favorable neurological outcomes. Patient characteristics including the cause and location of CA were not significantly different, except for a lower prevalence of chronic kidney disease in the survival group. The survival group had lower lactate levels (8.5 4.5–12.4 mmol/L vs. 10.8 6.2–14.0 mmol/L; p = 0.008), a higher pH (7.23 7.10–7.39 vs. 7.15 6.92–7.31; p = 0.013), and a higher pulse pressure after VA-ECMO implantation (24 8–39 mmHg vs. 23 0–37 mmHg; p = 0.012) compared to the non-survival group. APACHE II, SAPS II, and SAVE scores were significantly better in the survival group, with receiver operating characteristic (ROC) analysis showing area under the curve (AUC) values of 0.64, 0.61, and 0.61, respectively. The CTET was significantly shorter in the survival group (30 18–45 min vs. 40 25–54 min; p = 0.010) with an optimal threshold of 35 min based on ROC analysis (AUC = 0.61). Multivariable Cox regression analysis revealed that pH (Hazard ratio (HR) 0.27, 95% Confidence Interval (CI): 0.08–0.84; p = 0.024) and CTET (HR 1.02, 95% CI: 1.004–1.03; p = 0.008) were significantly associated with 30-day mortality. Conclusion A shorter CTET and the absence of low pH independently predicted better short-term prognosis in E-CPR patients with ECPELLA. Prompt VA-ECMO initiation and improved metabolic status may be key factors in improving outcomes in this population.
Inamori et al. (Sat,) studied this question.