Concurrent initiation of intra-aortic balloon pumping with extracorporeal membrane oxygenation reduced in-hospital mortality in postcardiotomy cardiogenic shock

Abstract

BackgroundVeno-arterial extracorporeal membrane oxygenation (VA-ECMO) is widely used in postcardiotomy cardiac shock (PCS). The factors that affect mortality in patients who receive ECMO for PCS remain unclear. In this study, we analyzed the outcomes, predictive factors and complications of ECMO use for PCS.MethodsA total of 152 adult subjects who received VA-ECMO for PCS in Fuwai Hospital were consecutively included. We retrospectively collected the baseline characteristics, outcomes and complications. Baseline characteristics were compared between survivors with non-survivors, and logistic regression was performed to identify predictive factors for in-hospital mortality.ResultsThe mean age of the subjects was 49.5 ± 14.1 years, with a male dominancy of 73.7%. The main surgical procedures were heart transplantation (32.2%), coronary artery bypass graft (17%) and valvular surgery (11.8%). Intra-aortic balloon pumping (IABP) was initiated concurrently with ECMO in 32.2% subjects and sequentially in 18.4% subjects. The ECMO weaning rate was 56.6%, and the in-hospital mortality was 52.0%. When compared with non-survivors, survivors had less hypertension (15.1% vs. 35.4%, p = 0.004), secondary thoracotomy before ECMO initiation (19.2% vs. 39.2%, p = 0.007), pre-ECMO cardiac arrest/ventricular fibrillation (11.0% vs. 34.2%, p = 0.001), bedside implantation of ECMO (11.0% vs. 41.8%, p < 0.001), and more transplant procedure (45.2% vs. 20.3%, p = 0.001), concurrent IABP initiation with ECMO (41.1% vs. 24.1%, p = 0.025). Multivariate logistic regression indicated concurrent IABP initiation with ECMO was the only independent protective factor for in-hospital mortality (OR = 0.375, p = 0.041, 95% CI 0.146–0.963). Concurrent IABP initiation with ECMO had less need for continuous renal replacement therapy (30.6% vs. 49.3%, p = 0.039) and less neurological complications (8.2% vs. 22.7%, p = 0.035), but more thrombosis complications (18.4% vs. 2.7%, p = 0.007).ConclusionConcurrent initiation of IABP with ECMO provides better short-term survival for PCS, with reduced peripheral perfusion complications.

The use of extracorporeal membrane oxygenation postcardiotomy—A systematic review

“…As VA‐ECMO increases afterload due to retrograde flow toward the aortic valve, this causes left ventricular distention that can result in pulmonary edema and hemorrhage 47,48 . The use of IABP helps to reduce afterload and improve coronary blood flow 49,50 . Alternatively, Impella use helps to support blood flow and unload the left ventricle; however, it does not improve coronary perfusion 50 .…”

Temporary Mechanical Circulatory Support in Acute Heart Failure

“…Combined support devices also facilitated cardiac function recovery in post-cardiotomy patients. [27][28][29] These findings underline that, despite apparent benefits from the combination of the two devices, further investigations are warranted to conclusively prove the actual role in cardiogenic shock patients requiring TCS.…”

Improve short-term survival in postcardiotomy cardiogenic shock by simultaneous use of intra-aortic balloon pumping with veno-arterial extracorporeal membrane oxygenation: Beware of confounders!

“…We enthusiastically read the recently published retrospective study by Chen et al [1] who demonstrated that simultaneous use of intra-aortic balloon pumping (IABP) together with veno-arterial extracorporeal membrane oxygenation (VA-ECMO) in postcardiotomy cardiogenic shock (PCS) patients improved short-term survival and reduced peripheral perfusion complications. In this study, 42 (28%) patients were on concomitant IABP and VA-ECMO [1]. While the study adds substantial value to the current knowledge, the current literature about the concomitant use of VA-ECMO and IABP remains controversial [2].…”

“…Reduced LV afterload and increased blood flow in the coronary arteries by IABP theoretically promote myocardial recovery and could potentially improve survival (although improved survival was never shown) [2, 3]. In the baseline characteristics of patients before VA-ECMO implantation among the non-survivors, they were significantly more hypertension (35 vs. 15%; P < .004), secondary thoracotomies (39 vs. 19%; P < .007), cardiac arrests (34 vs. 11%; P < .001), bedside implantations 42 vs. 11%; P < .0001) and significantly less concomitant insertions of VA-ECMO and IABP (22 vs. 41%; P < .025) when compared with the study survivors [1]. All mentioned variables are well-described risk factors for increased mortality [3].…”

“…All mentioned variables are well-described risk factors for increased mortality [3]. It is also reported that brain and kidney blood flow improves with concurrent initiation of IABP with ECMO [1]. Therefore, the question would be to find the mechanism by which concurrent initiation could reduce the need for continuous renal replacement therapy (CRRT) and decrease neurological complications [1].…”