Extracorporeal Membrane Oxygenation in the Therapy of Cardiogenic Shock: Results of the ECMO-CS Randomized Clinical Trial.

BACKGROUND: Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is increasingly being used for circulatory support in patients with cardiogenic shock, although the evidence supporting its use in this context remains insufficient. The ECMO-CS trial (Extracorporeal Membrane Oxygenation in the Therapy of Cardiogenic Shock) aimed to compare immediate implementation of VA-ECMO versus an initially conservative therapy (allowing downstream use of VA-ECMO) in patients with rapidly deteriorating or severe cardiogenic shock. METHODS: This multicenter, randomized, investigator-initiated, academic clinical trial included patients with either rapidly deteriorating or severe cardiogenic shock. Patients were randomly assigned to immediate VA-ECMO or no immediate VA-ECMO. Other diagnostic and therapeutic procedures were performed as per current standards of care. In the early conservative group, VA-ECMO could be used downstream in case of worsening hemodynamic status. The primary end point was the composite of death from any cause, resuscitated circulatory arrest, and implementation of another mechanical circulatory support device at 30 days. RESULTS: A total of 122 patients were randomized; after excluding 5 patients because of the absence of informed consent, 117 subjects were included in the analysis, of whom 58 were randomized to immediate VA-ECMO and 59 to no immediate VA-ECMO. The composite primary end point occurred in 37 (63.8%) and 42 (71.2%) patients in the immediate VA-ECMO and the no early VA-ECMO groups, respectively (hazard ratio, 0.72 [95% CI, 0.46-1.12]; P=0.21). VA-ECMO was used in 23 (39%) of no early VA-ECMO patients. The 30-day incidence of resuscitated cardiac arrest (10.3.% versus 13.6%; risk difference, -3.2 [95% CI, -15.0 to 8.5]), all-cause mortality (50.0% versus 47.5%; risk difference, 2.5 [95% CI, -15.6 to 20.7]), serious adverse events (60.3% versus 61.0%; risk difference, -0.7 [95% CI, -18.4 to 17.0]), sepsis, pneumonia, stroke, leg ischemia, and bleeding was not statistically different between the immediate VA-ECMO and the no immediate VA-ECMO groups. CONCLUSIONS: Immediate implementation of VA-ECMO in patients with rapidly deteriorating or severe cardiogenic shock did not improve clinical outcomes compared with an early conservative strategy that permitted downstream use of VA-ECMO in case of worsening hemodynamic status. REGISTRATION: URL: https://www. CLINICALTRIALS: gov; Unique identifier: NCT02301819.

Aortic dissection and other acute aortic syndromes in the emergency department.

Acute aortic syndromes are emergent life-threatening conditions affecting the aorta, which actual incidence is difficult to determine. Mortality of untreated patients increases steadily over time, so early diagnosis and initiation of therapy are crucial. Management of patients in Czech Republic follow, similar as in other European countries, the European Society of Cardiology guidelines from 2014, which were updated in 2018. The basis for diagnosis consists of history, physical examination, ECG, determination of vital signs, hemodynamic status and stratification of dia-gnosis probability by ADD-RS (aortic dissection detection risk score). This is followed by a series of laboratory and imaging examinations, of which the D-dimer, CT aortography and echocardiography are the most important. Recent studies show the benefit of combination of ADD-RS with D-dimer or measurement of ascendant aorta diameter by echocardiography. New emerging biomarkers are currently under investigation. Thanks to advances in technology, magnetic resonance imaging could take place as emergent diagnostic tool in the future. Initial therapy depends on the hemodynamic status of the patient. It must be followed by definitive therapy. In this publication we summarize the approach to a patient with acute aortic syndrome in the emergency department focusing on aortic dissection as its most common type.