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Meta-Analysis
. 2024 Mar 1;52(3):464-474.
doi: 10.1097/CCM.0000000000006157. Epub 2024 Jan 5.

Left-Ventricular Unloading With Impella During Refractory Cardiac Arrest Treated With Extracorporeal Cardiopulmonary Resuscitation: A Systematic Review and Meta-Analysis

Tharusan Thevathasan  1   2   3   4   5   6   7   8   9   10   11   12   13   14   15   16   17   18   19   20   21   22 , Lisa Füreder  1 , Marie Fechtner  1 , Sivagowry Rasalingam Mørk  5 , Benedikt Schrage  6   7 , Dirk Westermann  8 , Louise Linde  9 , Emilie Gregers  10 , Jo Bønding Andreasen  11 , Christopher Gaisendrees  12 , Takashi Unoki  13 , Andrea L Axtell  14 , Koji Takeda  15 , Alice V Vinogradsky  15 , Pedro Gonçalves-Teixeira  16 , Anthony Lemaire  17 , Marta Alonso-Fernandez-Gatta  18   19 , Hoong Sern Lim  20 , Arthur Reshad Garan  21 , Amarinder Bindra  22 , Gary Schwartz  22 , Ulf Landmesser  1   2   3   4   5   6   7   8   9   10   11   12   13   14   15   16   17   18   19   20   21   22 , Carsten Skurk  1   3
Affiliations
Meta-Analysis

Left-Ventricular Unloading With Impella During Refractory Cardiac Arrest Treated With Extracorporeal Cardiopulmonary Resuscitation: A Systematic Review and Meta-Analysis

Tharusan Thevathasan et al. Crit Care Med. .

Abstract

Objectives: Extracorporeal cardiopulmonary resuscitation (ECPR) is the implementation of venoarterial extracorporeal membrane oxygenation (VA-ECMO) during refractory cardiac arrest. The role of left-ventricular (LV) unloading with Impella in addition to VA-ECMO ("ECMELLA") remains unclear during ECPR. This is the first systematic review and meta-analysis to characterize patients with ECPR receiving LV unloading and to compare in-hospital mortality between ECMELLA and VA-ECMO during ECPR.

Data sources: Medline, Cochrane Central Register of Controlled Trials, Embase, and abstract websites of the three largest cardiology societies (American Heart Association, American College of Cardiology, and European Society of Cardiology).

Study selection: Observational studies with adult patients with refractory cardiac arrest receiving ECPR with ECMELLA or VA-ECMO until July 2023 according to the Preferred Reported Items for Systematic Reviews and Meta-Analysis checklist.

Data extraction: Patient and treatment characteristics and in-hospital mortality from 13 study records at 32 hospitals with a total of 1014 ECPR patients. Odds ratios (ORs) and 95% CI were computed with the Mantel-Haenszel test using a random-effects model.

Data synthesis: Seven hundred sixty-two patients (75.1%) received VA-ECMO and 252 (24.9%) ECMELLA. Compared with VA-ECMO, the ECMELLA group was comprised of more patients with initial shockable electrocardiogram rhythms (58.6% vs. 49.3%), acute myocardial infarctions (79.7% vs. 51.5%), and percutaneous coronary interventions (79.0% vs. 47.5%). VA-ECMO alone was more frequently used in pulmonary embolism (9.5% vs. 0.7%). Age, rate of out-of-hospital cardiac arrest, and low-flow times were similar between both groups. ECMELLA support was associated with reduced odds of mortality (OR, 0.53 [95% CI, 0.30-0.91]) and higher odds of good neurologic outcome (OR, 2.22 [95% CI, 1.17-4.22]) compared with VA-ECMO support alone. ECMELLA therapy was associated with numerically increased but not significantly higher complication rates. Primary results remained robust in multiple sensitivity analyses.

Conclusions: ECMELLA support was predominantly used in patients with acute myocardial infarction and VA-ECMO for pulmonary embolism. ECMELLA support during ECPR might be associated with improved survival and neurologic outcome despite higher complication rates. However, indications and frequency of ECMELLA support varied strongly between institutions. Further scientific evidence is urgently required to elaborate standardized guidelines for the use of LV unloading during ECPR.

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Conflict of interest statement

Drs. Schrage and Garan received funding from Abiomed. Dr. Schrage received funding from Abbott and AstraZeneca. Dr. Westermann received grants for honorary talks from AstraZeneca, Abiomed, Bayer, Boehringer Ingelheim, Edwards, Novartis, and Medtronic. Dr. Gregers received funding from the Odense University Hospital, Rigshospitalet’s Common Research Foundation, Novo Nordisk Foundation, and Beckett Foundation. Dr. Alonso-Fernandez-Gatta received funding from Instituto de Salud Carlos III (CM19/00055). Dr. Garan received funding from NuPulseCV and Maquet; he received support for article research from Abbott. The remaining authors have disclosed that they do not have any potential conflicts of interest.

Figures

Figure 1.
Figure 1.
Preferred Reported Items for Systematic Reviews and Meta-Analysis flow chart of study literature retrieval. ACC = American College of Cardiology, AHA = American Heart Association, CENTRAL = Cochrane Central Register of Controlled Trials, ECMELLA = concomitant treatment with venoarterial extracorporeal membrane oxygenation and Impella microaxial pump, ECPR = extracorporeal cardiopulmonary resuscitation, ESC = European Society of Cardiology, VA-ECMO = venoarterial extracorporeal membrane oxygenation.
Figure 2.
Figure 2.
Forest plot on in-hospital mortality (A) and good neurologic outcome (B) in patients treated with venoarterial extracorporeal membrane oxygenation (VA-ECMO) and Impella microaxial pump (ECMELLA) or VA-ECMO during extracorporeal cardiopulmonary resuscitation. The green arrow indicates a favor of ECMELLA therapy. The red arrow indicates a favor of VA-ECMO therapy. RE = random effect.
Figure 3.
Figure 3.
Funnel plot analysis.
See this image and copyright information in PMC

Comment in

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