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Multicenter Study
. 2025 Jan;27(1):40-50.
doi: 10.1002/ejhf.3498. Epub 2024 Oct 24.

Timing of veno-arterial extracorporeal membrane oxygenation support in patients with cardiogenic shock

Jonas Sundermeyer  1   2 , Caroline Kellner  1   3 , Benedikt N Beer  1   2 , Angela Dettling  1   2 , Lisa Besch  1   2 , Stefan Blankenberg  1   2   3 , Ingo Eitel  2   4 , Derk Frank  2   5 , Norbert Frey  6 , Tobias Graf  2   4 , Paulus Kirchhof  1   2   3   7 , Jannis Krais  8 , Dirk von Lewinski  9 , Norman Mangner  10 , Sven Möbius-Winkler  11 , Peter Nordbeck  12 , Martin Orban  13 , Matthias Pauschinger  14 , Can Martin Sag  8 , Clemens Scherer  13 , Carsten Skurk  15 , Holger Thiele  16 , Dirk Westermann  17 , Benedikt Schrage  1   2
Affiliations
Multicenter Study

Timing of veno-arterial extracorporeal membrane oxygenation support in patients with cardiogenic shock

Jonas Sundermeyer et al. Eur J Heart Fail. 2025 Jan.

Abstract

Aims: The optimal timing for implementing mechanical circulatory support (MCS) in cardiogenic shock (CS) remains indeterminate. This study aims to evaluate patient characteristics and outcome associated with the time interval between CS onset and veno-arterial extracorporeal membrane oxygenation (VA-ECMO) implementation.

Methods and results: In this study, patients with CS treated with MCS at 15 tertiary care centres in three countries were enrolled. Patients treated with MCS were stratified into early (<2 h), intermediate (2-12 h) and delayed (≥12-24 h) MCS implantation by using the time interval between CS onset and MCS device implementation. Adjusted logistic and Cox regression models were fitted to assess the association between timing of MCS implementation, patient characteristics and 30-day mortality. A total of 330 patients with CS treated with VA-ECMO and/or microaxial flow pump were included in this study; 20.9% received early, 55.8% intermediate, and 23.3% delayed MCS. Although crude 30-day mortality was slightly lower in patients with early MCS (58.1% vs. 64.7% vs. 64.3%), adjusted analyses showed no significant association between timing of MCS implantation and 30-day all-cause mortality (hazard ratio [HR] for early vs. intermediate MCS: 0.93, 95% confidence interval [CI] 0.59-1.46, p = 0.74; HR for early vs. delayed MCS: 1.29, 95% CI 0.78-2.13, p = 0.33). Moreover, the incidence of complications, related and unrelated to MCS, did not differ significantly among groups.

Conclusion: In this exploratory study of patients with CS treated with MCS, the timing of device implantation within 24 h after CS onset was not associated with mortality. This supports a restrictive MCS approach, reserving its application for patients experiencing CS deterioration despite conventional therapy.

Keywords: Cardiogenic shock; Extracorporeal membrane oxygenation; Mechanical circulatory support; Timing.

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Figures

Figure 1
Figure 1
Flowchart of the study cohort. CS, cardiogenic shock; eCPR, extracorporeal cardiopulmonary resuscitation; MCS, mechanical circulatory support; VA‐ECMO, veno‐arterial extracorporeal membrane oxygenation.
Figure 2
Figure 2
Association between patient characteristics and early versus delayed mechanical circulatory support (MCS) implementation in patients with cardiogenic shock (CS). To investigate differences in clinical characteristics during the index event between patients with early (<12 h) versus delayed (12–24 h) CS‐to‐MCS time intervals, multivariable mixed effects logistic regression models were fitted, adjusted for age, sex, lactate (before MCS implementation), cause of CS (acute myocardial infarction [AMI]‐related vs. heart failure‐related CS), and cardiopulmonary resuscitation (CPR). CI, confidence interval; SAPS II, Simplified Acute Physiology Score II; SAVE, Survival After Veno‐Arterial ECMO.
Figure 3
Figure 3
All‐cause 30‐day mortality stratified by early versus intermediate versus delayed mechanical circulatory support (MCS) implementation in patients with cardiogenic shock (CS). (A) Kaplan–Meier curve comparing patients with early (<2 h) versus intermediate (2–12 h) versus delayed (≥12–24 h) CS‐to‐MCS time intervals in patients with CS. (B) Hazard ratio for 30‐day mortality across the CS‐to‐MCS timing continuum, adjusted for age, sex, lactate (before MCS implementation), cause of CS (acute myocardial infarction‐related vs. heart failure‐related CS), and cardiopulmonary resuscitation.
Figure 4
Figure 4
All‐cause 30‐day mortality according to timing of mechanical circulatory support (MCS) implementation and stratified by cardiac arrest, extracorporeal membrane oxygenation (ECMO) only versus ECMELLA (Impella + ECMO), Survival After Veno‐Arterial ECMO (SAVE) and Simplified Acute Physiology score II (SAPS II), in patients with cardiogenic shock (CS). Thirty‐day mortality in patients with early, intermediate, and delayed CS‐to‐MCS time interval, stratified by: (A) cardiopulmonary resuscitation (CPR); (B) ECMO versus ECMELLA; (C) SAPS II score (stratified by < vs. ≥ median); (D) SAVE score (stratified by < vs. ≥ median).
Figure 5
Figure 5
Association between complications and early versus delayed implementation of mechanical circulatory support (MCS) in patients with cardiogenic shock (CS). To investigate complications during the hospital course between patients with early (<12 h) versus delayed (12–24 h) CS‐to‐MCS time, multivariable mixed effects logistic regression models were fitted, adjusted for age, sex, lactate (before MCS implementation), cause of CS (acute myocardial infarction‐related vs. heart failure‐related CS), and cardiopulmonary resuscitation. CI, confidence interval.
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