Extracorporeal life support during cardiac arrest and cardiogenic shock: a systematic review and meta-analysis

Abstract

PurposeVeno-arterial extracorporeal life support (ECLS) is increasingly used in patients during cardiac arrest and cardiogenic shock, to support both cardiac and pulmonary function. We performed a systematic review and meta-analysis of cohort studies comparing mortality in patients treated with and without ECLS support in the setting of refractory cardiac arrest and cardiogenic shock complicating acute myocardial infarction.MethodsWe systematically searched MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials and the publisher subset of PubMed updated to December 2015. Thirteen studies were included of which nine included cardiac arrest patients (n = 3098) and four included patients with cardiogenic shock after acute myocardial infarction (n = 235). Data were pooled by a Mantel-Haenzel random effects model and heterogeneity was examined by the I 2 statistic.ResultsIn cardiac arrest, the use of ECLS was associated with an absolute increase of 30 days survival of 13 % compared with patients in which ECLS was not used [95 % CI 6–20 %; p < 0.001; number needed to treat (NNT) 7.7] and a higher rate of favourable neurological outcome at 30 days (absolute risk difference 14 %; 95 % CI 7–20 %; p < 0.0001; NNT 7.1). Propensity matched analysis, including 5 studies and 438 patients (219 in both groups), showed similar results. In cardiogenic shock, ECLS showed a 33 % higher 30-day survival compared with IABP (95 % CI, 14–52 %; p < 0.001; NNT 13) but no difference when compared with TandemHeart/Impella (−3 %; 95 % CI −21 to 14 %; p = 0.70; NNH 33).ConclusionsIn cardiac arrest, the use of ECLS was associated with an increased survival rate as well as an increase in favourable neurological outcome. In the setting of cardiogenic shock there was an increased survival with ECLS compared with IABP.Electronic supplementary materialThe online version of this article (doi:10.1007/s00134-016-4536-8) contains supplementary material, which is available to authorized users.

Arteriovenous extracorporeal membrane oxygenation for cardiac arrest/cardiogenic shock

“…For example, VA-ECMO implantation is frequently performed in the angiography suite which in itself might be a marker of patient selection and percutaneous techniques furthermore seem to be associated with better outcomes [14]. It is essential that the cumulative evidence is systematically reviewed and presented as done by Ouweneel and colleagues [15] in a meta-analysis recently published in Intensive Care Medicine. The meta-analysis supports the results by de Chambrun et al [13] of improved survival using VA-ECMO in patients with cardiogenic shock after acute myocardial infarction as well as in refractory cardiac arrest, with improved Fig.…”

“…The meta-analysis supports the results by de Chambrun et al [13] of improved survival using VA-ECMO in patients with cardiogenic shock after acute myocardial infarction as well as in refractory cardiac arrest, with improved Fig. 1 Trial sequential analysis (TSA) for a relative risk reduction of mortality (left-hand graph) or unfavourable neurological outcome (right-hand graph) of 30% by VA-ECMO in refractory cardiac arrest and in cardiogenic shock following acute myocardial infarction using data from all studies included by Ouweneel et al [15]. Eleven studies including 2973 patients demonstrated a 50% relative risk reduction for death.…”

“…It also provides an estimate of the information size required as well as boundaries for futility to guide future trials. With the proviso that cardiac arrest/cardiogenic shock represents a continuum of disease, the studies reported by Ouweneel and colleagues [15] were pooled in a TSA and analysed for a relative risk reduction for death/poor neurological outcome by 30% (Fig. 1).…”

Recommendations for extracorporeal cardiopulmonary resuscitation (eCPR)

“…Beobachtungsstudien deuten darauf, dass die eCPR bei diesen selektierten IHCA-und OHCAPatienten im Vergleich mit der konventionellen CPR mit einer Zunahme der Überlebensrate von bis zu 30 % einhergeht [4,[13][14][15][16][17][18][19][20][21][22]. In einer Metaanalyse zeigte sich eine um 13 % verbesserte Überlebenswahrscheinlichkeit im Vergleich zur konventionellen CPR (95 %-Konfidenzintervall [95 %-KI] 6-20 %; p < 0,001; "number needed to treat" 7,7; [23] …”

Intra-aortic balloon pump during venoarterial extracorporeal membrane oxygenation: still a matter of debate? Contemporary multi-device approach to cardiogenic shock

“…So far, it is clear that this syndrome, with a stable mortality rate >40% as reported in most recent literature (1), requires a specific therapy. On top of medical therapy, mechanical circulatory support has emerged as the mainstay treatment for cardiogenic shock (1,2).…”