Left ventricular unloading in patients with cardiogenic shock treated with veno-arterial extracorporeal membrane oxygenation.

European heart journal open Pub Date : 2025-08-21 eCollection Date: 2025-09-01 DOI:10.1093/ehjopen/oeaf103
Bilaal Yousaf Dar, Gaayen Ravii Sahgal, Tavgah Jafar, Sangwoo R Jung, Mahmood Ahmad, Rui Bebiano Da Providencia E Costa, Iqra Javid, Syed Yousaf Ahmad, Malik Takreem Ahmad, Yusuf Abdirahman Yusuf, Abdulrahman Kashkosh
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引用次数: 0

Abstract

Aims: Cardiogenic shock remains a significant cause of mortality despite multiple advancements in medical interventions. Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) provides crucial circulatory support but also increases left ventricular (LV) after-load, potentially worsening outcomes. Effective LV unloading strategies can enhance patient survival during VA-ECMO treatment. Our aim was to evaluate the impact of LV unloading strategies, including intra-aortic balloon pump (IABP) and Impella, on outcomes such as mortality and adverse effects in patients with cardiogenic shock treated with VA-ECMO.

Methods and results: A systematic search of EMBASE and Medline was conducted from inception up to 20 August 2024. Additional sources included forward citation searches of primary references. Inclusion criteria were studies reporting mortality rates in patients undergoing VA-ECMO with and without LV unloading. Exclusion criteria included case studies, editorials, commentaries, literature reviews, studies without a control group, those not examining LV unloading, studies on non-cardiogenic shock patients, and paediatric populations. From 943 identified studies, 26 met the inclusion criteria after abstract and full text screening by two authors. Data extraction followed PRISMA guidelines with independent reviewers abstracting data and assessing study quality using the Cochrane Risk of Bias in non-randomized studies (ROBINS-I) tool. A random-effects model was used to pool data, accounting for study heterogeneity. The primary outcome was all-cause mortality, assessed at three time points: intra-hospital mortality, 30-day mortality and mortality at longest available follow-up. Secondary outcomes included adverse effects such as bleeding, infection, cardiovascular events, limb ischaemia, and renal replacement therapy (RRT). The meta-analysis included 26 studies with a total of 22 625 patients. LV unloading strategies significantly reduced mortality compared to no unloading (RR: 0.80; 95% CI: 0.73 to 0.96). IABP (RR: 0.78; 95% CI: 0.69 to 0.89) was associated with a significant reduction of mortality compared to no unloading. All adverse effects were comparable across groups apart from significantly increased infection rates and need for RRT in Impella patients (RR: 1.37; 95% CI: 1.07 to 1.75, and RR: 2.02; 95% CI: 1.37 to 3.00, respectively).

Conclusion: LV unloading strategies associated with reduced mortality in patients with cardiogenic shock treated with VA-ECMO. Whilst adverse effects are similar across all strategies, Impella specifically is linked to higher infection rates and need for RRT. These findings could be used to support the use of LV unloading devices in clinical practice and highlight the need for further randomized controlled trials to establish optimal device-options and management protocols.

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静脉-动脉体外膜氧合治疗心源性休克患者左心室负荷。
目的:心源性休克仍然是死亡率的重要原因,尽管在医疗干预方面取得了多项进展。静脉-动脉体外膜氧合(VA-ECMO)提供了至关重要的循环支持,但也增加了左心室(LV)后负荷,潜在地恶化了预后。有效的左室卸荷策略可提高VA-ECMO治疗期间患者的生存率。我们的目的是评估左室卸载策略,包括主动脉内球囊泵(IABP)和Impella,对VA-ECMO治疗心源性休克患者的死亡率和不良反应等结果的影响。方法与结果:系统检索EMBASE和Medline数据库,检索时间自成立至2024年8月20日。其他来源包括主要参考文献的转发引文搜索。纳入标准是报道有或没有左室卸荷的VA-ECMO患者死亡率的研究。排除标准包括病例研究、社论、评论、文献综述、没有对照组的研究、没有检查左室卸载的研究、非心源性休克患者的研究和儿科人群。经两位作者对摘要和全文筛选,943项研究中有26项符合纳入标准。数据提取遵循PRISMA指南,由独立审稿人提取数据,并使用Cochrane非随机研究偏倚风险(ROBINS-I)工具评估研究质量。随机效应模型用于汇集数据,考虑研究异质性。主要结局是全因死亡率,在三个时间点评估:院内死亡率、30天死亡率和最长随访时的死亡率。次要结局包括不良反应,如出血、感染、心血管事件、肢体缺血和肾脏替代治疗(RRT)。荟萃分析包括26项研究,共22 625名患者。左室卸药策略与未卸药相比显著降低死亡率(RR: 0.80; 95% CI: 0.73至0.96)。与未卸载相比,IABP (RR: 0.78; 95% CI: 0.69 ~ 0.89)与死亡率显著降低相关。除了Impella患者的感染率和RRT需求显著增加(RR: 1.37; 95% CI: 1.07至1.75,RR: 2.02; 95% CI: 1.37至3.00)外,各组间的所有不良反应均具有可比性。结论:左室卸荷策略与VA-ECMO治疗心源性休克患者死亡率降低相关。虽然所有策略的副作用相似,但Impella特别与较高的感染率和RRT的需求有关。这些发现可以用来支持在临床实践中使用左室卸载装置,并强调需要进一步的随机对照试验来建立最佳的设备选择和管理方案。
本文章由计算机程序翻译,如有差异,请以英文原文为准。
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