Outcomes of VA-ECMO with and without Left Centricular (LV) Decompression Using Intra-Aortic Balloon Pumping (IABP) versus Other LV Decompression Techniques: A Systematic Review and Meta-Analysis

Abstract

Background Left ventricular decompression is the primary method for solving VA-ECMO-induced LV afterload increase, but the effect of specific methods on patient outcomes and complications is unknown. Material/Methods We searched for all published reports conducted in patients undergoing ECMO combined with LVD. Statistical analyses were performed using Stata 12.0. Results The results showed that the risk of death with ECMO combined with LVD was 29% lower than that with ECMO alone (OR=0.71, 95% CI: 0.56–0.89, I 2 =59.5%, P < 0.001 ). Although the risk of death with ECMO combined other LV decompression techniques was higher than that with ECMO combined with IABP, the difference was not statistically significant (OR=1.27, 95% CI: 0.86–1.87, I 2 =44.0%, P = 0.057 ). In addition, the ORs values of hemorrhage, stroke/acute episodes, lower-limb ischemia, and hemolysis for ECMO combined with LVD were 0.69 (0.66–0.71), 0.82 (0.78–0.89), 0.71 (0.30–1.66), and 0.48 (0.16–1.39), respectively. The risk of complications, such as stroke/TIA, limb ischemia, and hemolysis, of ECMO combined with IABP was lower than that of ECMO combined other LV decompression techniques, and the risk of bleeding was higher for ECMO combined with IABP. Conclusions ECMO combined with LVD is more beneficial than using ECMO alone and helps to lower patient mortality.

Sensitivity of ventricular systolic function to afterload during veno‐arterial extracorporeal membrane oxygenation

“…Higher ECMO flows aimed to maintain adequate systemic perfusion to support end-organ function must be balanced against the risk of LV distension and its complications. [24][25][26] Apart from LV function, the optimal ECMO blood flow demands a fine balance between effects on microvascular and macrovascular parame-ters of tissue ischaemia, cerebral blood flow, haemolysis and platelet destruction, and centrifugal pump efficacy. 27,28 In our exploratory analysis, echocardiographic parameters had satisfactory performance in predicting potentially weanable patients with AUROC 0.86, which however drops to 0.68 for predicting patients who were ultimately decannulated from ECMO.…”

“…Higher ECMO flows aimed to maintain adequate systemic perfusion to support end‐organ function must be balanced against the risk of LV distension and its complications. 24 , 25 , 26 Apart from LV function, the optimal ECMO blood flow demands a fine balance between effects on microvascular and macrovascular parameters of tissue ischaemia, cerebral blood flow, haemolysis and platelet destruction, and centrifugal pump efficacy. 27 , 28 …”

“…The amplified afterload effect on depressing LV systolic function in the acute phase of ECMO implantation deserves special consideration during setting a ECMO target blood flow after implantation, for which a knowledge gap exists and the optimization is often left to individual clinical discretion. Higher ECMO flows aimed to maintain adequate systemic perfusion to support end‐organ function must be balanced against the risk of LV distension and its complications 24–26 . Apart from LV function, the optimal ECMO blood flow demands a fine balance between effects on microvascular and macrovascular parameters of tissue ischaemia, cerebral blood flow, haemolysis and platelet destruction, and centrifugal pump efficacy 27,28 …”

2023 Chinese Expert Consensus on the impact of COVID-19 on the management of cardiovascular diseases

“…There is evidence for greater benefit with ECMO than IABP [ 44 ] . Since VA-ECMO increases the left ventricular afterload, a combination of IABP and ECMO should be considered when satisfactory effects are not achieved using either IABP or ECMO alone [ 45 ] . Impella could be used in patients with right heart failure to increase right ventricular output and improve right heart function [ 46 ] .…”

Atualização de Tópicos Emergentes da Diretriz Brasileira de Insuficiência Cardíaca – 2021

“…75 Apesar das limitações conhecidas, o BIA permanece o dispositivo mais utilizado, com uma metanálise recente sugerindo menor risco de complicações como acidente vascular cerebral, isquemia periférica e hemólise, da descompressão por BIA em comparação com outros métodos, às custas do aumento de sangramento. 73 A qualidade da evidência avaliando riscos e benefícios da terapia paliativa com inotrópico intravenoso em regime ambulatorial para pacientes com IC avançada é limitada e composta principalmente por estudos observacionais e sem um grupo controle. Metanálises de pequenos estudos randomizados controlados e estudos observacionais heterogêneos sugerem um potencial benefício clínico da terapia inotrópica ambulatorial contínua ou intermitente em pacientes com IC avançada, que não são elegíveis para DACM ou transplante cardíaco.…”