Optimal ECLS Support in Mixed Cardiogenic and Septic Shock

Background

Mixed cardiogenic and septic shock has been shown to have a higher mortality than cardiogenic shock alone and presents a unique hemodynamic phenotype.

Objectives

This study aimed to evaluate whether higher circulatory support with veno-arterial extracorporeal life support (VA-ECLS) was associated with increased survival to discharge in patients with mixed shock.

Methods

We queried the Extracorporeal Life Support Organization database to identify adult (age >18 years) patients in mixed (cardiogenic and septic) shock requiring VA-ECLS between 2017 and 2022. Patients were categorized into lower (<2.2 L/min/m² flow) or higher (≥2.2 L/min/m² flow) circulatory support on VA-ECLS at 24 hours post-ECLS initiation.

Results

A total of 452 patients supported with VA-ECLS with mixed shock were identified. Overall mortality was 63% (n = 285). Older age (adjusted OR [aOR]: 1.02; 95% CI: 1.01-1.04; P < 0.001), pre-extracorporeal membrane oxygenation cardiac arrest (aOR: 1.71; 95% CI: 1.11-2.65; P = 0.016), and baseline Charlson Comorbidity Index (aOR: 1.13; 95% CI: 1.01-1.28; P = 0.043) were associated with increased mortality. Patients receiving higher VA-ECLS support at 24 hours were numerically more likely to survive to discharge (42.6% vs 33.8%, P = 0.063). When evaluated as a continuous variable, higher VA-ECLS flow at 24 hours was associated with an aOR of 1.31 (95% CI: 0.87-1.97; P = 0.19) for survival to discharge.

Conclusions

Patients with mixed shock requiring VA-ECLS have a high mortality. Patients with mixed shock receiving higher support at 24 hours had a trend toward increased survival to discharge compared to those with lower support. These results are hypothesis-generating, and further studies are needed.