Schrage Benedikt, Sundermeyer Jonas, Blankenberg Stefan, Colson Pascal, Eckner Dennis, Eden Matthias, Eitel Ingo, Frank Derk, Frey Norbert, Graf Tobias, Kirchhof Paulus, Kupka Danny, Landmesser Ulf, Linke Axel, Majunke Nicolas, Mangner Norman, Maniuc Octavian, Mierke Johannes, Möbius-Winkler Sven, Morrow David A, Mourad Marc, Nordbeck Peter, Orban Martin, Pappalardo Federico, Patel Sandeep M, Pauschinger Matthias, Pazzanese Vittorio, Radakovic Darko, Schulze P Christian, Scherer Clemens, Schwinger Robert H G, Skurk Carsten, Thiele Holger, Varshney Anubodh, Wechsler Lukas, Westermann Dirk
Department of Cardiology, University Heart and Vascular Center Hamburg, Hamburg, Germany; German Center for Cardiovascular Research, Partner Site Hamburg/Lübeck/Kiel, Hamburg, Germany.
Department of Cardiology, University Heart and Vascular Center Hamburg, Hamburg, Germany; German Center for Cardiovascular Research, Partner Site Hamburg/Lübeck/Kiel, Hamburg, Germany.
JACC Heart Fail. 2023 Mar;11(3):321-330. doi: 10.1016/j.jchf.2022.11.005. Epub 2023 Jan 11.
It is currently unclear if active left ventricular (LV) unloading should be used as a primary treatment strategy or as a bailout in patients with cardiogenic shock (CS) treated with venoarterial extracorporeal membrane oxygenation (VA-ECMO).
This study sought to evaluate the association between timing of active LV unloading and implantation of VA-ECMO with outcomes of patients with CS.
Data from 421 patients with CS treated with VA-ECMO and active LV unloading at 18 tertiary care centers in 4 countries were analyzed. Patients were stratified by timing of device implantation in early vs delayed active LV unloading (defined by implantation before up to 2 hours after VA-ECMO). Adjusted Cox and logistic regression models were fitted to evaluate the association between early active LV unloading and 30-day mortality as well as successful weaning from ventilation.
Overall, 310 (73.6%) patients with CS were treated with early active LV unloading. Early active LV unloading was associated with a lower 30-day mortality risk (HR: 0.64; 95% CI: 0.46-0.88) and a higher likelihood of successful weaning from ventilation (OR: 2.17; 95% CI: 1.19-3.93) but not with more complications. Importantly, the relative mortality risk increased and the likelihood of successful weaning from ventilation decreased almost proportionally with the time interval between VA-ECMO implantation and (delayed) initiation of active LV unloading.
This exploratory study lends support to the use of early active LV unloading in CS patients on VA-ECMO, although the findings need to be validated in a randomized controlled trial.
目前尚不清楚在接受静脉-动脉体外膜肺氧合（VA-ECMO）治疗的心源性休克（CS）患者中，主动左心室（LV）卸载应作为主要治疗策略还是作为补救措施。
本研究旨在评估主动LV卸载时机与VA-ECMO植入与CS患者结局之间的关联。
分析了来自4个国家18个三级医疗中心的421例接受VA-ECMO和主动LV卸载治疗的CS患者的数据。根据设备植入时机将患者分为早期与延迟主动LV卸载（定义为在VA-ECMO后2小时内植入）。采用校正的Cox和逻辑回归模型评估早期主动LV卸载与30天死亡率以及成功脱机之间的关联。
总体而言，310例（73.6%）CS患者接受了早期主动LV卸载。早期主动LV卸载与较低的30天死亡风险（HR：0.64；95%CI：0.46-0.88）和较高的成功脱机可能性（OR：2.17；95%CI：1.19-3.93）相关，但与更多并发症无关。重要的是，随着VA-ECMO植入与（延迟）开始主动LV卸载之间的时间间隔增加，相对死亡风险几乎成比例增加，成功脱机的可能性几乎成比例降低。
这项探索性研究支持在接受VA-ECMO的CS患者中使用早期主动LV卸载，尽管这些发现需要在随机对照试验中得到验证。
