Combined use of VA-ECMO and Impella (ECPELLA) improves short- and long-term mortality in patients with cardiogenic shock who received VA-ECMO
Authors: Unoki T , Nakayama T , Tsurusaki Y , Inamori T , Toyofuku T , Konami Y , Suzuyama H , Inoue M , Horio E , Kodama K , Taguchi E , Sawamura T , Sakamoto T , Nakao K , Koyama J 
Published: November 2023

Abstract

Introduction
Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is beneficial for patients with refractory cardiac arrest and cardiogenic shock. Despite its benefits, VA-ECMO increases left ventricular (LV) afterload and causes pulmonary edema and LV distension. Recently, a transcatheter left ventricular assist device, Impella has been introduced and potential benefits of the concomitant use of VA-ECMO and Impella (ECPELLA) are expected. However, with the concomitant increase in complications, the utility of ECPELLA remains controversial and unsettled.

Objective
This single-site cohort study aimed to assess the impact of ECPELLA compared to VA-ECMO with or without intra-aortic balloon pump (IABP) in patients with refractory cardiogenic shock, including cardiac arrest, who received VA-ECMO treatment.

Methods
We retrospectively reviewed 245 consecutive patients, who underwent VA-ECMO treatment between January 2012 and December 2021 at our institute. Seventeen patients for difficult weaning from cardiopulmonary bypass (n = 15) and as a backup during high-risk transcatheter aortic valve implantation (n = 2) were excluded. The patients were divided into two groups, ECEPLLA (n = 64) and VA-ECMO with or without IABP (n = 164). We performed propensity score analysis with 1:1 score matching using dependent variables of age, the rate of male gender, acute coronary syndrome, out-of-hospital and in-hospital cardiac arrest, and extracorporeal cardiopulmonary resuscitation. We evaluated hemodynamic data, safety profiles, and mortality.

Results
Following matching, 58 ECPELLA and 58 VA-ECMO patients were included for analysis. No significant differences in the adjusted factors and comorbidities were found between the two groups, except for a significantly higher prevalence of chronic kidney disease in the VA-ECMO group compared to the ECPELLA group. Seventy-one percent of patients received concomitant use of IABP in the VA-ECMO group. During the first 72 hours following the initiation of VA-ECMO, the ECPELLA group received a significantly higher total mechanical circulatory support flow and correspondingly less administration of catecholamines compared with the VA-ECMO group. There were no statistical differences in safety profiles, except for hemolysis and embolic cerebral infarction, between the treatment groups. Kaplan-Meier analysis demonstrated that the 30-day and 1-year survival rates were significantly higher in the ECPELLA group than in the VA-ECMO group. Multivariate cox proportional hazard analysis revealed that age (hazard ratio [HR], 1.36 [10 years increase]; 95% confidence interval [CI], 1.15–1.62, p &lt; 0.001), lactate level at ER (HR 1.07; 95% CI 1.03–1.12, p = 0.001), and ECPELLA (HR, 0.47, 95% CI, 0.30–0.73, p = 0.008) were significantly associated with the 1-year mortality.

Conclusion
ECPELLA was associated with improvement of short- and long-term mortality in patients with refractory cardiogenic shock who received VA-ECMO.Total MCS flow index and VISKaplan-Meier for 1-year mortality