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

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.

Cardiac power output index to define hemodynamic response to Impella support in cardiogenic shock.

BACKGROUND: Early assessment of response to Impella in cardiogenic shock may guide escalation of mechanical circulatory support. Therapeutic goal and response to Impella have not previously been defined. This study tested the hypothesis that targeting 3-h post- Impella cardiac power output index (CPOi)-"hemodynamic response"-in cardiogenic shock is associated with 12-h lactate clearance. METHODS: Single-center study of 37 consecutive patients who underwent left-sided Impella support for cardiogenic shock due to either acute myocardial infarction or decompensated heart failure. Patients who achieved 3-h post-Impella CPOi ⩾ 0.30 W/m2 were defined as Impella "hemodynamic responder." RESULTS: Twelve of the thirty-seven patients achieved 3-h post-impella CPOi ⩾ 0.30 W/m2 ("hemodynamic responders"). Post-Impella CPOi correlated with 12-h lactate (r = -0.779, p < 0.001) and lactate clearance (r = 0.747, p < 0.001). "Hemodynamic responders" had lower 12-h lactate level and greater 12-h lactate clearance (52 (44-58) vs 17 (14-26)%, p < 0.001). Higher pre-Impella norepinephrine dose (-0.341, p = 0.003) and baseline lactate (-0.009, p = 0.003) were independently associated with lower 3-h post-Impella CPOi. Eighteen patients died within 30 days (2/12 "hemodynamic responders" compared to 16/25 "non-responders," p < 0.001). CONCLUSION: Patients who achieved early 3-h post-Impella CPOi of ⩾0.30 W/m2 have greater lactate clearance and better short-term survival. Early post-Impella CPOi of 0.30 W/m2 may be used as a therapeutic goal and define favorable response to Impella in cardiogenic shock.

Baseline MELD-XI score and outcome from veno-arterial extracorporeal membrane oxygenation support for acute decompensated heart failure.

BACKGROUND: Acute decompensated heart failure is the most common acute heart failure phenotype. Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) can provide bridging support for patients with acute decompensated heart failure to transplantation. We studied the association between baseline (<6 months), pre-ECMO (<24 h) parameters and outcome of VA-ECMO support in patients with severe acute decompensated heart failure. METHODS: We included 26 consecutive patients with acute decompensated heart failure (acute myocarditis, myocardial infarction or post-cardiotomy shock were excluded) who were bridged with peripheral VA-ECMO to transplantation. Data within six months (baseline) and immediately pre-ECMO were collected. Model for end-stage liver disease (MELD) with sodium (MELD-Na) and without international normalized ratio (MELD-XI) scores were calculated. Outcome was defined as death at 30 days following VA-ECMO support. RESULTS: Thirteen of the 26 patients died within 30 days of VA-ECMO support. Univariate associations with 30-day mortality were baseline MELD-XI, baseline sodium, creatinine, bilirubin, pre-ECMO alanine aminotransferase and lactate. However, only baseline MELD-XI score (hazard ratio 2.678 (95% CI 1.085-6.607), p=0.033) was associated 30-day survival on logistic regression analysis. Survivors demonstrated greater reduction in inotropic and vasoactive drug support and improvement in alanine aminotransferase and lactate levels. Using a threshold based on the median MELD-XI of 14.1, 30-day survival in patients with a baseline MELD-XI ⩽ 14.1 was 69% compared with 31% in patients with baseline MELD-XI > 14.1 ( p=0.046). CONCLUSION: Baseline MELD-XI score, but not pre-ECMO parameters, is independently associated with outcomes from VA-ECMO support in patients with acute decompensated heart failure.