• Benedikt Schrage, BecherPeter MoritzPMDepartments of Cardiology (B.S., P.M.B., S. Blankenberg, S.D., A.G., P.K., D.W.), University Heart and Vascular Center Hamburg, Germany.German Center for Cardiovascular Research (DZHK), partner site Hamburg/Lübeck/Kiel, Germany (B.S., , Alexander Bernhardt, Hiram Bezerra, Stefan Blankenberg, Stefan Brunner, Pascal Colson, Gaston Cudemus Deseda, Salim Dabboura, Dennis Eckner, Matthias Eden, Ingo Eitel, Derk Frank, Norbert Frey, Masaki Funamoto, Alina Goßling, Tobias Graf, Christian Hagl, Paulus Kirchhof, Danny Kupka, Ulf Landmesser, Jerry Lipinski, Mathew Lopes, Nicolas Majunke, Octavian Maniuc, Daniel McGrath, Sven Möbius-Winkler, David A Morrow, Marc Mourad, Curt Noel, Peter Nordbeck, Martin Orban, Federico Pappalardo, Sandeep M Patel, Matthias Pauschinger, Vittorio Pazzanese, Hermann Reichenspurner, Marcus Sandri, P Christian Schulze, H G SchwingerRobertRMedizinische Klinik II, Klinikum Weiden, Germany (R.H.G.S., L.W.)., Jan-Malte Sinning, Adem Aksoy, Carsten Skurk, Lukasz Szczanowicz, Holger Thiele, Franziska Tietz, Anubodh Varshney, Lukas Wechsler, and Dirk Westermann.
• Departments of Cardiology (B.S., P.M.B., S. Blankenberg, S.D., A.G., P.K., D.W.), University Heart and Vascular Center Hamburg, Germany.
• Circulation. 2020 Dec 1; 142 (22): 2095-2106.

BackgroundVenoarterial extracorporeal membrane oxygenation (VA-ECMO) is increasingly used to treat cardiogenic shock. However, VA-ECMO might hamper myocardial recovery. The Impella unloads the left ventricle. This study aimed to evaluate whether left ventricular unloading in patients with cardiogenic shock treated with VA-ECMO was associated with lower mortality.MethodsData from 686 consecutive patients with cardiogenic shock treated with VA-ECMO with or without left ventricular unloading using an Impella at 16 tertiary care centers in 4 countries were collected. The association between left ventricular unloading and 30-day mortality was assessed by Cox regression models in a 1:1 propensity score-matched cohort.ResultsLeft ventricular unloading was used in 337 of the 686 patients (49%). After matching, 255 patients with left ventricular unloading were compared with 255 patients without left ventricular unloading. In the matched cohort, left ventricular unloading was associated with lower 30-day mortality (hazard ratio, 0.79 [95% CI, 0.63-0.98]; P=0.03) without differences in various subgroups. Complications occurred more frequently in patients with left ventricular unloading: severe bleeding in 98 (38.4%) versus 45 (17.9%), access site-related ischemia in 55 (21.6%) versus 31 (12.3%), abdominal compartment in 23 (9.4%) versus 9 (3.7%), and renal replacement therapy in 148 (58.5%) versus 99 (39.1%).ConclusionsIn this international, multicenter cohort study, left ventricular unloading was associated with lower mortality in patients with cardiogenic shock treated with VA-ECMO, despite higher complication rates. These findings support use of left ventricular unloading in patients with cardiogenic shock treated with VA-ECMO and call for further validation, ideally in a randomized, controlled trial.

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