Journal
JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY
Volume 79, Issue 13, Pages 1239-1250Publisher
ELSEVIER SCIENCE INC
DOI: 10.1016/j.jacc.2022.01.032
Keywords
intra-aortic balloon pump; percutaneous ventricular assist device; survival; unloading; venoarterial extracorporeal membrane oxygenation
Categories
Funding
- National Institutes of Health/National Heart, Lung, And Blood Institute [K23 HL141596]
- National Institutes of Health [K08 GM134220-01, R01 DK125786-01]
- Abbott Vascular
- Verantos
- Abbott
- Abiomed
- Boston Scientific
- Getinge
- LivaNova
- Medtronic
- MDStart
- Precardia
- Zoll
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Among adults receiving VA-ECMO, mechanical unloading (MU) with intra-aortic balloon pump (IABP) or percutaneous ventricular assist device (pVAD) was associated with lower in-hospital mortality and increased complications. Compared to pVAD, MU with IABP had similar mortality and lower complication rates.
BACKGROUND Venoarterial extracorporeal membrane oxygenation (VA-ECMO) increases left ventricular (LV) after-load, potentially provoking LV distention and impairing recovery. LV mechanical unloading (MU) with intra-aortic balloon pump (IABP) or percutaneous ventricular assist device (pVAD) can prevent LV distension, potentially at the risk of more complications, and net clinical benefit remains uncertain. OBJECTIVES This study aims to determine the association between MU and outcomes for patients undergoing VA-ECMO. METHODS The authors queried the Extracorporeal Life Support Organization registry for adults receiving peripheral VA-ECMO from 2010 to 2019 and stratified them by MU with IABP or pVAD. The primary outcome was in-hospital mortality; secondary outcomes included on-support mortality and complications during VA-ECMO. RESULTS Among 12,734 VA-ECMO patients, 3,399 (26.7%) received MU: 2,782 (82.9%) IABP and 580 (17.1%) pVAD. MU patients were older (age 56.3 vs 52.7 years) and, before extracorporeal membrane oxygenation, more often required >2 vasopressors (41.7% vs 27.2%) and had respiratory (21.1% vs 15.9%), renal (24.6% vs 15.8%), and liver failure (4.4% vs 3.1%) (all P < 0.001). MU patients had lower in-hospital mortality (56.6% vs 59.3%, P = 0.006), which persisted in multivariable modeling (adjusted OR [aOR]: 0.84; 95% CI: 0.77-0.92; P < 0.001). MU was associated with more cannula site bleeding (aOR: 1.25; 95% CI: 1.11-1.40; P < 0.001) and hemolysis (aOR: 1.27; 95% CI: 1.03-1.57; P = 0.02). Compared to pVAD, MU patients with IABP had similar mortality (aOR: 0.80; 95% CI: 0.64-1.01; P = 0.06) and less medical bleeding (aOR: 0.45; 95% CI: 0.31-0.64; P < 0.001), cannula site bleeding (aOR: 0.72; 95% CI: 0.54-0.96; P = 0.03), and renal injury (aOR: 0.78; 95% CI: 0.62-0.98; P = 0.03). CONCLUSIONS Among adults receiving VA-ECMO, MU was associated with lower in-hospital mortality despite increased complications including hemolysis and cannulation site bleeding. Compared to pVAD, MU with IABP was associated with similar mortality and lower complication rates. (C) 2022 by the American College of Cardiology Foundation.
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