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Meta-Analysis
. 2021 Apr;8(2):1064-1075.
doi: 10.1002/ehf2.13080. Epub 2020 Dec 18.

Veno-Arterial Extracorporeal Life Support in Heart Transplant and Ventricle Assist Device Centres. Meta-analysis

Mariusz Kowalewski  1   2   3 , Kamil Zieliński  4 , Mirosław Gozdek  3   5 , Giuseppe Maria Raffa  6 , Michele Pilato  6 , Musab Alanazi  2 , Martijn Gilbers  2 , Sam Heuts  2 , Ehsan Natour  2 , Elham Bidar  2 , Rick Schreurs  2 , Thijs Delnoij  7   8 , Rob Driessen  7   8 , Jan Willem Sels  7   8 , Marcel van de Poll  8 , Paul Roekaerts  8 , Michał Pasierski  1 , Paolo Meani  7   8 , Jos Maessen  2 , Piotr Suwalski  1 , Roberto Lorusso  2   9
Affiliations
Meta-Analysis

Veno-Arterial Extracorporeal Life Support in Heart Transplant and Ventricle Assist Device Centres. Meta-analysis

Mariusz Kowalewski et al. ESC Heart Fail. 2021 Apr.

Abstract

Aims: Because reported mortality on veno-arterial (V-A) extracorporeal life support (ECLS) substantially varies between centres, the aim of the current analysis was to assess the outcomes between units performing heart transplantation and/or implanting ventricular assist device (HTx/VAD) vs. non-HTx/VAD units in patients undergoing V-A ECLS for cardiogenic shock.

Methods and results: Systematic search according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses was performed using PubMed/MEDLINE databases until 30 November 2019. Articles reporting in-hospital/30-day mortality and centre's HTx/VAD status were included. In-hospital outcomes and long-term survival were analysed in subgroup meta-analysis. A total of 174 studies enrolling n = 13 308 patients were included with 20 series performed in non-HTx/VAD centres (1016 patients, 7.8%). Majority of patients underwent V-A ECLS for post-cardiotomy shock (44.2%) and acute myocardial infarction (20.7%). Estimated overall in-hospital mortality was 57.2% (54.9-59.4%). Mortality rates were higher in non-HTx/VAD [65.5% (59.8-70.8%)] as compared with HTx/VAD centres [55.8% (53.3-58.2%)], P < 0.001. Estimated late survival was 61.8% (55.7-67.9%) without differences between non-HTx/VAD and HTx/VAD centres: 66.5% (30.3-1.02%) vs. 61.7% (55.5-67.8%), respectively (P = 0.797). No differences were seen with respect to ECLS duration, limb complications, and reoperations for bleeding, kidney injury, and sepsis. Yet, weaning rates were higher in HTx/VAD vs. non-HTx/VAD centres: 58.7% (56.2-61.1%) vs. 48.9% (42.0-55.9%), P = 0.010. Estimated rate of bridge to heart transplant was 6.6% (5.2-8.3%) with numerical, yet not statistically significant, difference between non-HTx/VAD [2.7% (0.8-8.3%)] as compared with HTx/VAD [6.7% (5.3-8.6%)] (P = 0.131).

Conclusions: Survival after V-A ECLS differed according to centre's HTx/VAD status. Potentially different risk profiles of patients must be taken account for before definite conclusions are drawn.

Keywords: Acute heart failure; Cardiogenic shock; Extracorporeal life support; Meta-analysis.

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Conflict of interest statement

Dr Lorusso is consultant and conducts clinical trial for LivaNova (London, UK), is consultant for Medtronic (Minneapolis, MN), and an Advisory Board member of PulseCath (Arnhem, The Netherlands). The other authors have no conflicts of interest to disclose.

Figures

Figure 1
Figure 1
Study selection process according to Preferred Reporting Items for Systematic Reviews and Meta‐Analyses guidelines.
Figure 2
Figure 2
Distribution of patients across range of indications for veno‐arterial extracorporeal membrane oxygenation.
Figure 3
Figure 3
Analysis of in‐hospital mortality, complications, bridge to VAD/HTx, and remote survival following V‐A ECLS institution in non‐HTx/VAD vs. HTx/VAD centres. Squares represent point estimates of pooled studies; horizontal lines are respective 95% confidence intervals. HTx, heart transplantation; VAD, ventricle assist device.
Figure 4
Figure 4
Analysis of bridging to HTx and/or VAD following V‐A ECLS institution in non‐HTx/VAD vs. HTx/VAD centres. Squares represent point estimates of pooled studies; horizontal lines are respective 95% confidence intervals. HTx, heart transplantation; VAD, ventricle assist device.
Figure 5
Figure 5
Meta‐regression analysis: in‐hospital mortality vs. post‐cardiotomy shock (%). The size of the circle corresponds to the inverse variance and thus is related to the statistical weight of the individual study.
Figure 6
Figure 6
Proposed algorithm of patient management: V‐A ECMO in cardiogenic shock with respect to potential referral to HTx/VAD centre. CK‐MB, creatin kinase muscle‐brain isoenzyme; CVVH, continuous veno‐venous haemofiltration; HTx, heart transplantation; LV/RV, left/right ventricle; V‐A ECMO, veno‐arterial extracorporeal membrane oxygenation; VAD, ventricle assist device.
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