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. 2022 Apr 5;79(13):1239-1250.
doi: 10.1016/j.jacc.2022.01.032.

Mechanical Left Ventricular Unloading in Patients Undergoing Venoarterial Extracorporeal Membrane Oxygenation

E Wilson Grandin  1 , Jose I Nunez  2 , Brooks Willar  3 , Kevin Kennedy  4 , Peter Rycus  5 , Joseph E Tonna  6 , Navin K Kapur  7 , Shahzad Shaefi  8 , A Reshad Garan  9
Affiliations

Mechanical Left Ventricular Unloading in Patients Undergoing Venoarterial Extracorporeal Membrane Oxygenation

E Wilson Grandin et al. J Am Coll Cardiol. .

Abstract

Background: Venoarterial extracorporeal membrane oxygenation (VA-ECMO) increases left ventricular (LV) afterload, 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.

Keywords: intra-aortic balloon pump; percutaneous ventricular assist device; survival; unloading; venoarterial extracorporeal membrane oxygenation.

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Conflict of interest statement

Funding Support and Author Disclosures Dr Tonna has received a Career Development Award from the National Institutes of Health/National Heart, Lung, And Blood Institute (K23 HL141596); has received speaker fees and travel compensation from LivaNova, unrelated to this work; and is the Chair of the ELSO Registry Scientific Oversight Committee. Dr Kapur has received institutional research support and speaker/consulting honoraria from Abbott, Abiomed, Boston Scientific, Getinge, LivaNova, Medtronic, MDStart, Precardia, and Zoll. Dr Shaefi has received grants from the National Institutes of Health (K08 GM134220-01 and R01 DK125786-01). Dr Garan has received research support from Abbott Vascular and Verantos; and has received consultant fees from Abiomed and NupulseCV. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.

Figures

FIGURE 1
FIGURE 1. Flow Diagram of Patient Selection
Flow chart of patient selection for the analytic cohort. IABP = intra-aortic balloon pump; LV = left ventricle; pVAD = percutaneous ventricular assist device; VA-ECMO = venoarterial extracorporeal membrane oxygenation.
FIGURE 2
FIGURE 2. Left Ventricular Mechanical Unloading and In-Hospital Mortality Across Subgroups
Forest plot of the OR (95% CI) from multivariable logistic regression modeling examining the interaction of key clinical subgroups on the association of left ventricular mechanical unloading and in-hospital mortality in VA-ECMO patients. CHF = congestive heart failure; ECMO = extracorporeal membrane oxygenation; ECPR = extracorporeal cardiopulmonary resuscitation; VA-ECMO = venoarterial extracorporeal membrane oxygenation; VT/VF = ventricular tachycardia/ventricular fibrillation.
FIGURE 3
FIGURE 3. VA-ECMO Outcomes With IABP vs pVAD for Left Ventricular Mechanical Unloading
Forest plot of the OR (95% CI) from multivariable logistic regression modeling examining the association of left ventricular mechanical unloading with IABP versus pVAD and outcomes in VA-ECMO patients. IABP = intra-aortic balloon pump; pVAD = percutaneous ventricular assist device; other abbreviation as in Figure 2.
CENTRAL ILLUSTRATION
CENTRAL ILLUSTRATION. Left Ventricular Mechanical Unloading during Venoarterial Extracorporeal Membrane Oxygenation: Temporal Trends and Association With Outcomes
(A) Rates of left ventricular mechanical unloading with intra-aortic balloon pump (IABP) or percutaneous ventricular assist device (pVAD) in patients undergoing venoarterial extracorporeal membrane oxygenation (VA-ECMO) from 2010 to 2019. (B) Forest plot of the OR (95% CI) from multivariable logistic regression modeling examining the association of left ventricular mechanical unloading and outcomes in VA-ECMO patients.
See this image and copyright information in PMC

Comment in

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