Revisiting VA-ECMO in infarct-related cardiogenic shock.

Despite advances in medical therapies and coronary revascularisation, infarct-related cardiogenic shock remains a life-threatening emergency with high death rates. 1 Lauridsen MD Rørth R Lindholm MG et al. Trends in first-time hospitalization, management, and short-term mortality in acute myocardial infarction-related cardiogenic shock from 2005 to 2017: a nationwide cohort study. Am Heart J. 2020; 229: 127-137 Crossref PubMed Scopus (0) Google Scholar Temporary mechanical circulatory support, including peripheral venoarterial extracorporeal membrane oxygenation (VA-ECMO), is a potential option for this condition as it can instantly improve haemodynamics while simultaneously providing gas exchange for acute cardiorespiratory failure. 2 Rao P Khalpey Z Smith R Burkhoff D Kociol RD Venoarterial extracorporeal membrane oxygenation for cardiogenic shock and cardiac arrest. Circ Heart Fail. 2018; 11e004905 Crossref Scopus (246) Google Scholar However, this is an expensive and invasive strategy that requires large-bore vascular access and can result in serious complications including bleeding, peripheral ischaemia, and stroke. Since its introduction in 1972, 3 Hill JD O'Brien TG Murray JJ et al. Prolonged extracorporeal oxygenation for acute post-traumatic respiratory failure (shock-lung syndrome). Use of the Bramson membrane lung. N Engl J Med. 1972; 286: 629-634 Crossref PubMed Google Scholar there has been a marked increase in VA-ECMO use for cardiogenic shock, although whether it improves outcomes in these patients is still unknown. 4 Stretch R Sauer CM Yuh DD Bonde P National trends in the utilization of short-term mechanical circulatory support: incidence, outcomes, and cost analysis. J Am Coll Cardiol. 2014; 64: 1407-1415 Crossref PubMed Scopus (358) Google Scholar Observational data have been limited by residual confounding, not allowing for causal interpretation. Recent randomised clinical trials (RCTs) have attempted to provide answers; however, these have often been underpowered, reflecting the difficulty of conducting RCTs during acute critical illness. 5 Brunner S Guenther SPW Lackermair K et al. Extracorporeal life support in cardiogenic shock complicating acute myocardial infarction. J Am Coll Cardiol. 2019; 73: 2355-2357 Crossref PubMed Scopus (56) Google Scholar , 6 Ostadal P Rokyta R Karasek J et al. Extracorporeal membrane oxygenation in the therapy of cardiogenic shock: results of the ECMO-CS randomized clinical trial. Circulation. 2023; 147: 454-464 Crossref PubMed Scopus (44) Google Scholar , 7 Banning AS Sabate M Orban M et al. Venoarterial extracorporeal membrane oxygenation or standard care in patients with cardiogenic shock complicating acute myocardial infarction: the multicentre, randomised EURO SHOCK trial. EuroIntervention. 2023; (published online May 19.)https://doi.org/10.4244/EIJ-D-23-00204 Crossref Google Scholar As such, current recommendations for the use of VA-ECMO in cardiogenic shock are based on a low level of evidence. 8 McDonagh TA Metra M Adamo M et al. 2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure. Eur Heart J. 2021; 42: 3599-3726 Crossref PubMed Scopus (3714) Google Scholar Venoarterial extracorporeal membrane oxygenation in patients with infarct-related cardiogenic shock: an individual patient data meta-analysis of randomised trialsVA-ECMO did not reduce 30-day death rate compared with medical therapy alone in patients with infarct-related cardiogenic shock, and an increase in major bleeding and vascular complications was observed. A careful review of the indication for VA-ECMO in this setting is warranted. Full-Text PDF