Left-ventricular Unloading With Impella® During Refractory Cardiac Arrest Treated With Extracorporeal Cardiopulmonary Resuscitation - A Systematic Review and Meta-analysis.

Tharusan Thevathasan (Berlin)1, L. Füreder (Berlin)1, M. Fechtner (Berlin)1, S. R. Mørk (Aarhus)2, B. Schrage (Hamburg)3, D. Westermann (Freiburg im Breisgau)4, L. Linde (Odense)5, E. Gregers (Copenhagen)6, J. B. Andreasen (Aalborg)7, C. Gaisendrees (Köln)8, T. Unoki (Kumamoto City)9, A. L. Axtell (Boston)10, K. Takeda (New York)11, A. V. Vinogradsky (New York)11, P. Gonçalves-Teixeira (Oporto)12, A. Lemaire (New Brunswick)13, M. Alonso-Fernandez-Gatta (Salamanca)14, H. S. Lim (Birmingham)15, A. R. Garan (Boston)16, A. Bindra (Dallas)17, G. Schwartz (Dallas)17, U. Landmesser (Berlin)1, C. Skurk (Berlin)1

1Deutsches Herzzentrum der Charité (CBF) Klinik für Kardiologie, Angiologie und Intensivmedizin Berlin, Deutschland; 2Aarhus University Hospital Department of Cardiology Aarhus, Dänemark; 3Universitäres Herz- und Gefäßzentrum Hamburg Klinik für Kardiologie Hamburg, Deutschland; 4Universitäts-Herzzentrum Freiburg - Bad Krozingen Innere Medizin III, Kardiologie und Angiologie Freiburg im Breisgau, Deutschland; 5Odense University Hospital Department of Cardiology, Odense, Dänemark; 6Copenhagen University Hospital Department of Cardiology Copenhagen, Dänemark; 7Aalborg University Hospital Department of Aneastesiology and Intensive Care Aalborg, Dänemark; 8Universitätsklinikum Köln Köln, Deutschland; 9Saiseikai Kumamoto Hospital Department of Cardiology and Intensive Care Unit Kumamoto City, Japan; 10Massachusetts General Hospital, Harvard Medical School Division of Cardiac Surgery Boston, USA; 11Columbia University Medical Center, New York-Presbyterian Hospital Department of Surgery New York, USA; 12Centro Hospitalar de Vila Nova de Gaia Department of Cardiology Oporto, Portugal; 13Rutgers-Robert Wood Johnson Medical School Division of Cardiothoracic Surgery New Brunswick, USA; 14University Hospital of Salamanca Cardiology Department Salamanca, Spanien; 15Queen Elizabeth Hospital Birmingham Department of Cardiology Birmingham, Deutschland; 16Beth Israel Deaconess Medical Center, Harvard Medical School Division of Cardiology Boston, USA; 17Baylor University Medical Center Center for Advanced Heart and Lung Disease Dallas, USA


Objective: Extracorporeal cardio-pulmonary resuscitation (ECPR) is the implementation of veno-arterial extracorporeal membrane oxygenation (VA-ECMO) during refractory cardiac arrest. The role of left-ventricular (LV) unloading with Impella® in addition to VA-ECMO (“ECMELLA”) remains unclear during ECPR. This is the first systematic review and meta-analysis to characterize patients with ECPR receiving LV unloading and to compare in-hospital mortality and complications between ECMELLA and VA-ECMO during ECPR.
Data Sources: Medline, Cochrane Central Register of Controlled Trials (CENTRAL), Embase and abstract websites of the three largest cardiology societies (American Heart Association, American College of Cardiology and European Society of Cardiology).
Study Selection: Observational studies with adult patients with refractory cardiac arrest receiving ECPR with ECMELLA or VA-ECMO until July 2023 according to the PRISMA checklist.
Data Extraction: Patient and treatment characteristics, in-hospital mortality and complications from 13 study records at 32 hospitals with a total of 1,014 ECPR patients. Odds ratios (OR) and 95% confidence interval (CI) were computed with the Mantel-Haenszel test using a random-effects model.
Data Synthesis: 762 patients (75.1%) received VA-ECMO and 252 (24.9%) ECMELLA. Compared to VA-ECMO, the ECMELLA group was comprised of more patients with initial shockable ECG rhythms (58.6% vs. 49.3%), acute myocardial infarctions (79.7% vs. 51.5%) and percutaneous coronary interventions (79.0% vs. 47.5%). VA-ECMO alone was more frequently used in pulmonary embolism (9.5% vs. 0.7%). Age, rate of out-of-hospital cardiac arrest and low-flow times were similar between both groups. ECMELLA support was associated with reduced odds of mortality (OR 0.53 [95% CI 0.30-0.91]) and higher odds of good neurological outcome (OR 2.22 [95% CI 1.17-4.22]) compared to VA-ECMO support alone (see Figure). ECMELLA therapy was associated with numerically increased but not significantly higher complication rates. Primary results remained robust in multiple sensitivity analyses.
Conclusions: ECMELLA support was predominantly utilized in patients with acute myocardial infarction and VA-ECMO for pulmonary embolism. ECMELLA support during ECPR might be associated with improved survival and neurologic outcome despite higher complication rates. Though, indications and frequency of ECMELLA support varied strongly between institutions. Further scientific evidence is urgently required to elaborate standardized guidelines for the use of LV unloading during ECPR.

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