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. 2023 Mar;11(3):321-330.
doi: 10.1016/j.jchf.2022.11.005. Epub 2023 Jan 11.

Timing of Active Left Ventricular Unloading in Patients on Venoarterial Extracorporeal Membrane Oxygenation Therapy

Benedikt Schrage  1 , Jonas Sundermeyer  2 , Stefan Blankenberg  2 , Pascal Colson  3 , Dennis Eckner  4 , Matthias Eden  5 , Ingo Eitel  6 , Derk Frank  7 , Norbert Frey  5 , Tobias Graf  6 , Paulus Kirchhof  8 , Danny Kupka  9 , Ulf Landmesser  10 , Axel Linke  11 , Nicolas Majunke  12 , Norman Mangner  11 , Octavian Maniuc  13 , Johannes Mierke  11 , Sven Möbius-Winkler  14 , David A Morrow  15 , Marc Mourad  3 , Peter Nordbeck  13 , Martin Orban  16 , Federico Pappalardo  17 , Sandeep M Patel  18 , Matthias Pauschinger  4 , Vittorio Pazzanese  19 , Darko Radakovic  20 , P Christian Schulze  14 , Clemens Scherer  16 , Robert H G Schwinger  21 , Carsten Skurk  10 , Holger Thiele  12 , Anubodh Varshney  15 , Lukas Wechsler  21 , Dirk Westermann  22
Affiliations
Free article

Timing of Active Left Ventricular Unloading in Patients on Venoarterial Extracorporeal Membrane Oxygenation Therapy

Benedikt Schrage et al. JACC Heart Fail. 2023 Mar.
Free article

Abstract

Background: It is currently unclear if active left ventricular (LV) unloading should be used as a primary treatment strategy or as a bailout in patients with cardiogenic shock (CS) treated with venoarterial extracorporeal membrane oxygenation (VA-ECMO).

Objectives: This study sought to evaluate the association between timing of active LV unloading and implantation of VA-ECMO with outcomes of patients with CS.

Methods: Data from 421 patients with CS treated with VA-ECMO and active LV unloading at 18 tertiary care centers in 4 countries were analyzed. Patients were stratified by timing of device implantation in early vs delayed active LV unloading (defined by implantation before up to 2 hours after VA-ECMO). Adjusted Cox and logistic regression models were fitted to evaluate the association between early active LV unloading and 30-day mortality as well as successful weaning from ventilation.

Results: Overall, 310 (73.6%) patients with CS were treated with early active LV unloading. Early active LV unloading was associated with a lower 30-day mortality risk (HR: 0.64; 95% CI: 0.46-0.88) and a higher likelihood of successful weaning from ventilation (OR: 2.17; 95% CI: 1.19-3.93) but not with more complications. Importantly, the relative mortality risk increased and the likelihood of successful weaning from ventilation decreased almost proportionally with the time interval between VA-ECMO implantation and (delayed) initiation of active LV unloading.

Conclusions: This exploratory study lends support to the use of early active LV unloading in CS patients on VA-ECMO, although the findings need to be validated in a randomized controlled trial.

Trial registration: ClinicalTrials.gov NCT05577195.

Keywords: cardiogenic shock; extracorporeal membrane oxygenation; left ventricular unloading.

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Conflict of interest statement

Funding Support and Author Disclosures Drs Schrage and Westermann were funded by the German Center for Cardiovascular Research, and Dr Schrage is also funded by the Else Kröner-Fresenius-Stiftung. This study was funded by an unrestricted research grant from Abiomed. However, Abiomed was not involved in the design of the study, the collection and analysis of the data, the writing of the manuscript, or the decision to publish. Dr Schrage has received speaker fees from Abiomed and AstraZeneca, outside of the submitted work. Dr Blankenberg has received grants and personal fees from Abbott Diagnostics, Bayer, Siemens, and Thermo Fisher; grants from Singulex; and personal fees from Abbott, AstraZeneca, AMGEN, Medtronic, Pfizer, Roche, Siemens Diagnostics, and Novartis, outside of the submitted work. Dr Eckner has received speaker fees from Abiomed, Bayer, and Daiichi Sankyo, outside of the submitted work. Dr Kirchhof has received research support for basic, translational, and clinical research projects from the European Union, British Heart Foundation, Leducq Foundation, Medical Research Council (United Kingdom), and German Center for Cardiovascular Research; has received research support from several drug and device companies active in atrial fibrillation; has received honoraria from several such companies in the past but not in the last 3 years; and is listed as inventor on 2 patents held by the University of Birmingham (Atrial Fibrillation Therapy WO 2015140571, Markers for Atrial Fibrillation WO 2016012783; unrelated to the submitted work). Dr Mangner has received personal fees from Edwards Lifesciences, Medtronic, Biotronik, Novartis, Sanofi Genzyme, AstraZeneca, Pfizer, Bayer, Abbott, Abiomed, and Boston Scientific, outside the submitted work. Dr Mierke has received speaker fees from Abiomed, outside the submitted work. Dr Morrow has served as a member of the TIMI Study Group, which has received institutional research grant support through Brigham and Women’s Hospital from Abbott Laboratories, Amgen, Anthos Therapeutics, Arca Biopharma, AstraZeneca, Bayer HealthCare Pharmaceuticals, Daiichi Sankyo, Eisai, Intarcia, Janssen, Merck, Novartis, Pfizer, Quark Pharmaceuticals, Regeneron, Roche, Siemens, The Medicines Company, and Zora Biosciences; and received consulting fees from Arca Biopharma, Bayer Pharma, InCarda, Inflammatix, Merck, Novartis, and Roche Diagnostics. Dr Pappalardo has served as a consultant for Abiomed. Dr Westermann has received speaker fees from Abiomed, AstraZeneca, Bayer, Berlin-Chemie, Boehringer Ingelheim, Novartis, and Medtronic, outside of the submitted work. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.

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