Abstract

 

OBJECTIVES

Patients in cardiogenic shock supported with venoarterial extracorporeal membrane oxygenation (VA-ECMO) may experience severe complications from reduced left ventricular (LV) unloading and increased cardiac afterload. These effects are usually modified by adding a percutaneous direct Impella vent or surgical LV vent on top of VA-ECMO in selected patients. However, direct comparisons between 2 LV unloading strategies in patients with cardiogenic shock due to myocardial infarction are lacking. Therefore, we sought to investigate the impact of these 2 different approaches.

METHODS

We enrolled 112 patients treated with an Impella or surgical LV vent during VA-ECMO support between January 2014 and February 2020. The primary endpoint was 30-day mortality. Secondary endpoints included rates of myocardial recovery or transition to durable mechanical circulatory support. Additionally, we assessed adverse events such as peripheral ischaemic complications requiring intervention, sepsis and ischaemic stroke.

RESULTS

At 30 days, 38 patients in the Impella group (54%) and 26 patients in the surgical LV vent group (63%) had died (relative risk with Impella 0.78, 95% confidence interval 0.47–1.30; P = 0.35). Impella group and the surgical LV vent group differed significantly with respect to the secondary end points including rates of myocardial recovery (24% and 7%, respectively; P = 0.022) and rates of durable mechanical circulatory support (17% and 42%, P = 0.012). Complication rates were not statistically different between the 2 groups.

CONCLUSIONS

The use of Impella device as therapeutic unloading therapy during VA-ECMO did not significantly reduce 30-day mortality compared to surgical LV vent in patients with cardiogenic shock due to acute myocardial infarction.

中文翻译：

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心源性休克心肌梗死体外生命支持期间左心室卸载：手术通气与 Impella 装置

摘要

 

目标

静脉动脉体外膜肺氧合 (VA-ECMO) 支持的心源性休克患者可能会因左心室 (LV) 卸载减少和心脏后负荷增加而出现严重并发症。这些效果通常通过在选定患者的 VA-ECMO 顶部添加经皮直接 Impella 通气口或外科 LV 通气口来改变。然而，缺乏对心肌梗死所致心源性休克患者 2 种 LV 卸载策略的直接比较。因此，我们试图调查这两种不同方法的影响。

方法

在 2014 年 1 月至 2020 年 2 月期间，我们招募了 112 名在 VA-ECMO 支持期间接受 Impella 或外科 LV 通气治疗的患者。主要终点是 30 天死亡率。次要终点包括心肌恢复率或过渡到持久的机械循环支持。此外，我们评估了不良事件，例如需要干预的外周缺血性并发症、败血症和缺血性中风。

结果

在 30 天时，Impella 组的 38 名患者 (54%) 和手术 LV 通气组的 26 名患者 (63%) 死亡（Impella 的相对风险为 0.78，95% 置信区间为 0.47-1.30；P  = 0.35）。Impella 组和手术 LV 通气组在次要终点方面存在显着差异，包括心肌恢复率（分别为 24% 和 7%；P  = 0.022）和持久机械循环支持率（17% 和 42%，P  = 0.012)。并发症发生率在两组之间没有统计学差异。

结论

与因急性心肌梗死导致的心源性休克患者进行左室通气手术相比，在 VA-ECMO 期间使用 Impella 装置作为治疗性卸载治疗并未显着降低 30 天死亡率。