Department of Cardiology, Royal Brompton and Harefield Hospitals, Guy's and St Thomas' NHS Foundation Trust, Harefield Hospital, UB9 6JH Harefield, UK.
Cardiovascular Sciences, National Heart and Lung Institute, Imperial College, SW3 6LY London, UK.
Rev Cardiovasc Med. 2021 Dec 22;22(4):1503-1511. doi: 10.31083/j.rcm2204154.
Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is used as mechanical circulatory support in cardiogenic shock (CS). It restores peripheral perfusion, at the expense of increased left ventricle (LV) afterload. In this setting, Impella can be used as direct unloading strategy. Aim of this meta-analysis was to investigate efficacy and safety of LV unloading with Impella during ECMO in CS. A systematic search on Medline, Scopus and Cochrane Library was performed using as combination of keywords: extracorporeal membrane oxygenation, Impella, percutaneous micro axial pump, ECPELLA, cardiogenic shock. We aimed to include studies, which compared the use of ECMO with and without Impella (ECPELLA vs. ECMO). Primary endpoint was short-term all-cause mortality; secondary endpoints included major bleeding, haemolysis, need for renal replacement therapy (RRT) and cerebrovascular accident (CVA). Five studies met the inclusion criteria, with a total population of 972 patients. The ECPELLA cohort showed improved survival compared to the control group (RR (Risk Ratio): 0.86; 95% CI (Confidence Interval): 0.76, 0.96; = 0.009). When including in the analysis only studies with homogeneous comparator groups, LV unloading with Impella remained associated with significant reduction in mortality (RR: 0.85; 95% CI: 0.75, 0.97; = 0.01). Haemolysis (RR: 1.70; 95% CI: 1.35, 2.15; < 0.00001) and RRT (RR: 1.86; 95% CI: 1.07, 3.21; = 0.03) occurred at a higher rate in the ECPELLA group. There was no difference between the two groups in terms of major bleeding (RR: 1.37; 95% CI: 0.88, 2.13; = 0.16) and CVA (RR: 0.91; 95% CI: 0.61, 1.38; = 0.66). In conclusion, LV unloading with Impella during ECMO was associated with improved survival, despite increased haemolysis and need for RRT, without additional risk of major bleeding and CVA.
静脉-动脉体外膜肺氧合（VA-ECMO）在心源性休克（CS）中用作机械循环支持。它恢复外周灌注，同时增加左心室（LV）后负荷。在这种情况下，可以使用 Impella 作为直接卸载策略。这项荟萃分析的目的是研究在 CS 中使用 ECMO 时 LV 卸载与 Impella 的疗效和安全性。我们在 Medline、Scopus 和 Cochrane Library 上进行了系统搜索，使用了组合关键词：体外膜肺氧合、Impella、经皮微轴流泵、ECPELLA、心源性休克。我们旨在纳入比较 ECMO 联合和不联合 Impella（ECPELLA 与 ECMO）使用的研究。主要终点是短期全因死亡率；次要终点包括主要出血、溶血、需要肾脏替代治疗（RRT）和脑血管意外（CVA）。五项研究符合纳入标准，共有 972 名患者。ECPELLA 组的存活率高于对照组（RR（风险比）：0.86；95%CI（置信区间）：0.76，0.96； = 0.009）。当仅将具有同质比较组的研究纳入分析时，Impella 辅助 LV 卸载仍与死亡率显著降低相关（RR：0.85；95%CI：0.75，0.97； = 0.01）。溶血（RR：1.70；95%CI：1.35，2.15； ＜0.00001）和 RRT（RR：1.86；95%CI：1.07，3.21； = 0.03）在 ECPELLA 组中的发生率更高。两组之间在主要出血（RR：1.37；95%CI：0.88，2.13； = 0.16）和 CVA（RR：0.91；95%CI：0.61，1.38； = 0.66）方面无差异。结论，尽管溶血和 RRT 的需求增加，但在 ECMO 期间使用 Impella 辅助 LV 卸载可提高生存率，且不会增加主要出血和 CVA 的风险。
