Advertisement

Meta-Analysis Comparing Venoarterial Extracorporeal Membrane Oxygenation With or Without Impella in Patients With Cardiogenic Shock

      Cardiogenic shock is associated with high short-term mortality. Venoarterial extracorporeal membrane oxygenation (VA-ECMO) is increasingly used as a mechanical circulatory support strategy for patients with refractory cardiogenic shock. A drawback of this hemodynamic support strategy is increased left ventricular (LV) afterload, which is mitigated by concomitant use of Impella (extracorporeal membrane oxygenation with Impella [ECPELLA]). However, data regarding the benefits of this approach are limited. We conducted a systematic search of Medline, EMBASE, and Cochrane databases to identify studies including patients with cardiogenic shock reporting clinical outcomes with Impella plus VA-ECMO compared with VA-ECMO alone. Primary outcome was short-term all-cause mortality (in-hospital or 30-day mortality). Secondary outcomes included major bleeding, hemolysis, continuous renal replacement therapy, weaning from mechanical circulatory support, limb ischemia, and transition to destination therapy with LV assist device (LVAD) or cardiac transplant. Of 2,790 citations, 7 observational studies were included. Of 1,054 patients with cardiogenic shock, 391 were supported with ECPELLA (37%). Compared with patients on only VA-ECMO support, patients with ECPELLA had a lower risk of short-term mortality (risk ratio [RR] 0.89 [0.80 to 0.99], I2 = 0%, p = 0.04) and were significantly more likely to receive a heart transplant/LVAD (RR 2.03 [1.44 to 2.87], I2 = 0%, p <0.01). However, patients with ECPELLA had a higher risk of hemolysis (RR 2.03 [1.60 to 2.57], I2 = 0%, p <0.001), renal failure requiring continuous renal replacement therapy (RR 1.46 [1.23 to 174], I2 = 11%, p <0.0001), and limb ischemia (RR 1.67 [1.15 to 2.43], I2 = 0%, p = 0.01). In conclusion, among patients with cardiogenic shock requiring VA-ECMO support, concurrent LV unloading with Impella had a lower likelihood of short-term mortality and a higher likelihood of progression to durable LVAD or heart transplant. However, patients supported with ECPELLA had higher rates of hemolysis, limb ischemia, and renal failure requiring continuous renal replacement therapy. Future prospective randomized are needed to define the optimal treatment strategy in this high-risk cohort.

      Abbreviations:

      CI (Confidence intervals), CRRT (Continous renal replacement therapy), ECPELLA (VA-ECMO and Impella), LVAD (Left ventricular assist device), LV (Left ventricular), RR (Risk ratios), VA-ECMO (Veno-arterial extracorporeal membrane oxygenation)
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to American Journal of Cardiology
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Osman M
        • Syed M
        • Patibandla S
        • Sulaiman S
        • Kheiri B
        • Shah MK
        • Bianco C
        • Balla S
        • Patel B.
        Fifteen-year trends in incidence of cardiogenic shock hospitalization and in-hospital mortality in the United States.
        J Am Heart Assoc. 2021; 10e021061
      1. American Heart Association. Trends in incidence, management, and outcomes of cardiogenic shock complicating ST-elevation myocardial infarction in the United States. Available at: http://www.ahajournals.org/doi/epub/10.1161/JAHA.113.000590. Accessed on May 21, 2021.

        • Thiele H
        • Ohman EM
        • Desch S
        • Eitel I
        • de Waha S.
        Management of cardiogenic shock.
        Eur Heart J. 2015; 36: 1223-1230
        • Vallabhajosyula S
        • Prasad A
        • Bell MR
        • Sandhu GS
        • Eleid MF
        • Dunlay SM
        • Schears GJ
        • Stulak JM
        • Singh M
        • Gersh BJ
        • Jaffe AS
        • Holmes Jr, DR
        • Rihal CS
        • Barsness GW.
        Extracorporeal membrane oxygenation use in acute myocardial infarction in the United States, 2000 to 2014.
        Circ Heart Fail. 2019; 12e005929
      2. SpringerLink. High mortality associated with intracardiac and intrapulmonary thromboses after cardiopulmonary bypass. Available at: https://link.springer.com/article/10.1007/s00540-011-1253-x. Accessed on April 15, 2021 |.

        • Koeckert MS
        • Jorde UP
        • Naka Y
        • Moses JW
        • Takayama H.
        Impella LP 2.5 for left ventricular unloading during venoarterial extracorporeal membrane oxygenation support.
        J Card Surg. 2011; 26: 666-668
        • Combes A
        • Price S
        • Slutsky AS
        • Brodie D.
        Temporary circulatory support for cardiogenic shock.
        Lancet. 2020; 396: 199-212
        • Higgins JPT
        • Thompson SG
        • Deeks JJ
        • Altman DG.
        Measuring inconsistency in meta-analyses.
        BMJ. 2003; 327: 557-560
        • Egger M
        • Davey Smith G
        • Schneider M
        • Minder C
        Bias in meta-analysis detected by a simple, graphical test.
        BMJ. 1997; 315: 629-634
        • Pappalardo F
        • Schulte C
        • Pieri M
        • Schrage B
        • Contri R
        • Soeffker G
        • Greco T
        • Lembo R
        • Müllerleile K
        • Colombo A
        • Sydow K
        • De Bonis M
        • Wagner F
        • Reichenspurner H
        • Blankenberg S
        • Zangrillo A
        • Westermann D.
        Concomitant implantation of Impella® on top of veno-arterial extracorporeal membrane oxygenation may improve survival of patients with cardiogenic shock.
        Eur J Heart Fail. 2017; 19: 404-412
        • Akanni OJ
        • Takeda K
        • Truby LK
        • Kurlansky PA
        • Chiuzan C
        • Han J
        • Topkara VK
        • Yuzefpolskaya M
        • Colombo PC
        • Karmpaliotis D
        • Moses JW
        • Naka Y
        • Garan AR
        • Kirtane AJ
        • Takayama H.
        EC-VAD: combined use of extracorporeal membrane oxygenation and percutaneous microaxial pump left ventricular assist device.
        ASAIO J. 2019; 65: 219-226
      3. Singh A. Impact of Left ventricular Decompression with Impella During venoarterial Extracorporeal Membrane Oxygenation Support in acute myocardial infarction complicated by Cardiogenic Shock. SCAI. Available at: https://scai.confex.com/scai/2019/webprogram/Paper2758.html. Accessed on April 17, 2021.

        • Patel SM
        • Lipinski J
        • Al-Kindi SG
        • Patel T
        • Saric P
        • Li J
        • Nadeem F
        • Ladas T
        • Alaiti A
        • Phillips A
        • Medalion B
        • Deo S
        • Elgudin Y
        • Costa MA
        • Osman MN
        • Attizzani GF
        • Oliveira GH
        • Sareyyupoglu B
        • Bezerra HG.
        Simultaneous venoarterial extracorporeal membrane oxygenation and percutaneous left ventricular decompression therapy with Impella is associated with improved outcomes in refractory cardiogenic shock.
        ASAIO J. 2019; 65: 21-28
        • Kunavarapu C
        • Kwan M
        • Sterling R
        • Tran R
        • Rodriguez SM
        • Dellavolpe J
        • Habib P
        • Talathoti J
        • Crist B
        • Pearson C
        • Ono M.
        Cardiogenic shock spectrum: outcomes utilizing VA ECMO with or without axillary Impella 5.0: Single Center experience.
        J Heart Lung Transplant. 2020; 39: S424-S425
        • Schrage B
        • Becher PM
        • Bernhardt A
        • Bezerra H
        • Blankenberg S
        • Brunner S
        • Colson P
        • Cudemus Deseda G
        • Dabboura S
        • Eckner D
        • Eden M
        • Eitel I
        • Frank D
        • Frey N
        • Funamoto M
        • Goßling A
        • Graf T
        • Hagl C
        • Kirchhof P
        • Kupka D
        • Landmesser U
        • Lipinski J
        • Lopes M
        • Majunke N
        • Maniuc O
        • McGrath D
        • Möbius-Winkler S
        • Morrow DA
        • Mourad M
        • Noel C
        • Nordbeck P
        • Orban M
        • Pappalardo F
        • Patel SM
        • Pauschinger M
        • Pazzanese V
        • Reichenspurner H
        • Sandri M
        • Schulze PC
        • H G Schwinger R
        • Sinning JM
        • Aksoy A
        • Skurk C
        • Szczanowicz L
        • Thiele H
        • Tietz F
        • Varshney A
        • Wechsler L
        • Westermann D
        Left ventricular unloading is associated with lower mortality in patients with cardiogenic shock treated with venoarterial extracorporeal membrane oxygenation: Results from an international, multicenter cohort study.
        Circulation. 2020; 142: 2095-2106
        • Garan AR
        • Takeda K
        • Salna M
        • Vandenberge J
        • Doshi D
        • Karmpaliotis D
        • Kirtane AJ
        • Takayama H
        • Kurlansky P.
        Prospective comparison of a percutaneous ventricular assist device and venoarterial extracorporeal membrane oxygenation for patients with cardiogenic shock following acute myocardial infarction.
        J Am Heart Assoc. 2019; 8e012171
        • Shah M
        • Patnaik S
        • Patel B
        • Ram P
        • Garg L
        • Agarwal M
        • Agrawal S
        • Arora S
        • Patel N
        • Wald J
        • Jorde UP.
        Trends in mechanical circulatory support use and hospital mortality among patients with acute myocardial infarction and non-infarction related cardiogenic shock in the United States.
        Clin Res Cardiol. 2018; 107: 287-303
        • Truby LK
        • Takeda K
        • Mauro C
        • Yuzefpolskaya M
        • Garan AR
        • Kirtane AJ
        • Topkara VK
        • Abrams D
        • Brodie D
        • Colombo PC
        • Naka Y
        • Takayama H
        Incidence and implications of left ventricular distention during venoarterial extracorporeal membrane oxygenation support.
        ASAIO J. 2017; 63: 257-265
        • Makdisi G
        • Wang IW.
        Extra Corporeal Membrane Oxygenation (ECMO) review of a lifesaving technology.
        J Thorac Dis. 2015; 7: E166-E176
        • Lim HS.
        The effect of Impella CP on cardiopulmonary physiology during venoarterial extracorporeal membrane oxygenation support.
        Artif Organs. 2017; 41: 1109-1112
        • Belohlavek J
        • Hunziker P
        • Donker DW.
        Left ventricular unloading and the role of ECpella.
        Eur Heart J Suppl. 2021; 23: A27-A34
        • Chen Z
        • Zhang J
        • Kareem K
        • Tran D
        • Conway RG
        • Arias K
        • Griffith BP
        • Wu ZJ
        Device-induced platelet dysfunction in mechanically assisted circulation increases the risks of thrombosis and bleeding.
        Artif Organs. 2019; 43: 745-755