University of Ottawa Heart Institute, Ottawa, Ontario, Canada.
Toronto General Hospital, Toronto, Ontario, Canada.
J Am Coll Cardiol. 2019 Feb 19;73(6):654-662. doi: 10.1016/j.jacc.2018.10.085.
Venoarterial extracorporeal membrane oxygenation (VA-ECMO) is a widely used form of mechanical circulatory support in patients with refractory cardiogenic shock. A common drawback of this modality is a resultant increase in left ventricular afterload.
The purpose of this meta-analysis was to examine the efficacy and safety of left ventricular unloading strategies during VA-ECMO in adult patients with cardiogenic shock.
The authors performed a systematic search of studies examining left ventricular unloading during VA-ECMO in Medline, EMBASE, and the Cochrane library. The primary outcome was all-cause mortality. Secondary outcomes included limb ischemia, bleeding, need for renal replacement therapy, multiorgan failure, stroke or transient ischemic attack, and hemolysis.
Of 2,221 publications identified, 17 observational studies met the inclusion criteria. In total, outcomes in 3,997 patients were included with 1,696 (42%) receiving a concomitant left ventricular unloading strategy while on VA-ECMO (intra-aortic balloon pump 91.7%, percutaneous ventricular assist device 5.5%, pulmonary vein or transseptal left atrial cannulation 2.8%). There were 2,412 deaths (60%) in the total cohort. Mortality was lower in patients with (54%) versus without (65%) left ventricular unloading while on VA-ECMO (risk ratio: 0.79; 95% confidence interval: 0.72 to 0.87; p < 0.00001). Hemolysis was higher in patients who underwent VA-ECMO with left ventricular unloading. Otherwise, secondary outcomes were not demonstrably different in patients treated with VA-ECMO with versus without left ventricular unloading.
In observational studies, left ventricular unloading was associated with decreased mortality in adult patients with cardiogenic shock treated with VA-ECMO. In the absence of prospective randomized data, left ventricular unloading may be considered for appropriately selected patients undergoing VA-ECMO support.
在难治性心源性休克患者中，静脉-动脉体外膜肺氧合（VA-ECMO）是一种广泛使用的机械循环支持形式。这种方式的一个常见缺点是左心室后负荷增加。
本荟萃分析的目的是研究在成人心源性休克患者中使用 VA-ECMO 时左心室减压策略的疗效和安全性。
作者在 Medline、EMBASE 和 Cochrane 图书馆中进行了一项系统检索，以研究在 VA-ECMO 期间进行左心室减压的研究。主要结局是全因死亡率。次要结局包括肢体缺血、出血、需要肾脏替代治疗、多器官衰竭、中风或短暂性脑缺血发作以及溶血。
在 2221 篇已确定的文献中，有 17 项观察性研究符合纳入标准。共有 3997 例患者的结局被纳入，其中 1696 例（42%）在接受 VA-ECMO 时接受了同时的左心室减压策略（主动脉内球囊泵 91.7%，经皮心室辅助装置 5.5%，肺静脉或经房间隔左心房插管 2.8%）。在总队列中，有 2412 例（60%）死亡。在接受 VA-ECMO 治疗的患者中，接受左心室减压的患者死亡率（54%）低于未接受左心室减压的患者（65%）（风险比：0.79；95%置信区间：0.72 至 0.87；p<0.00001）。在接受 VA-ECMO 治疗并伴有左心室减压的患者中，溶血发生率更高。否则，接受 VA-ECMO 治疗并伴有或不伴有左心室减压的患者的次要结局并无明显差异。
在观察性研究中，在接受 VA-ECMO 治疗的心源性休克成人患者中，左心室减压与死亡率降低相关。在缺乏前瞻性随机数据的情况下，对于接受 VA-ECMO 支持的适当选择患者，可考虑左心室减压。
