Early Left Atrial Septostomy Versus Conventional Approach After Venoarterial Extracorporeal Membrane Oxygenation

Study Overview
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Brief Summary
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The use of venoarterial-extracorporeal membrane oxygenation(VA-ECMO) was associated with lower in-hospital mortality in patients with cardiogenic shock. However, VA-ECMO has a deleterious effect for hemodynamics. It can increase left ventricular end-diastolic pressure(LVEDP), followed by left ventricular dilatation, abnormal opening of aortic valve and jeopardizes of myocardial recovery. Therefore, several methods have been used to reduce LVEDP. Among these, left atrial septostomy is effective, but less invasive than surgical left ventricular unloading. However, there is few data regarding this issue. Therefore, the investigators will evaluate the effect of routine, early left atrial septostomy in patients with VA-ECMO for the treatment of cardiogenic shock.

Detailed Description
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Study Objectives: To determine the effect of early left atrial septostomy versus conventional approach(left atrial septostomy only in cases of significant changes due to left ventricular end-diastolic pressure increase) in patients who received venoarterial-extracorporeal membrane oxygenation(VA-ECMO) for the treatment of cardiogenic shock. Study Background: Cardiogenic shock is due to myocardial dysfunction from multifactorial causes, which has high mortality. The treatment for cardiogenic shock includes early coronary revascularization, inotropes, vasopressors, or mechanical circulatory support, such as intraaortic balloon pump(IABP), VA-ECMO. However, the routine use of IABP is not recommended for the treatment of cardiogenic shock in recent guidelines. VA-ECMO can be easily implanted, and can maintain high cardiac output. In several studies, The use of VA-ECMO was associated with lower in-hospital mortality in patients with cardiogenic shock. However, VA-ECMO has a deleterious effect for hemodynamics. It can increase left ventricular end-diastolic pressure(LVEDP), followed by left ventricular dilatation, abnormal opening of aortic valve and jeopardizes of myocardial recovery. Therefore, several methods have been used to reduce LVEDP. Among these, left atrial septostomy is effective, but less invasive than surgical left ventricular unloading. However, there is few data regarding this issue. Therefore, the investigators will evaluate the effect of routine, early left atrial septostomy in patients with VA-ECMO for the treatment of cardiogenic shock. Study Hypothesis: Early, routine left atrial septostomy for left heart unloading is superior compared to conventional approach to reduce in-hospital mortality and the duration of VA-ECMO.

Official Title
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Early Left Atrial Septostomy Versus Conventional Approach After Venoarterial Extracorporeal Membrane Oxygenation: A Randomized Controlled Study

Conditions
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Cardiogenic Shock

Intervention / Treatment
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* Procedure: Early left atrial septostomy within 12 hours after VA-ECMO implantation
* Procedure: Selective left atrial septostomy


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: 1) Age more than 18 years old 2) Cardiogenic shock* 3) Successful VA-ECMO implantation The definition of cardiogenic shock All these criteria should be met Systolic blood pressure < 90 mmHg for 30 minutes, or needing inotrope or vasopressor to maintain systolic blood pressure > or = 90 mmHg Pulmonary congestion on chest X-ray or increased left ventricular filling pressure by cardiac catheterization At least one criteria of organ dysfunction - mental obtundation, clammy skin, oliguria, renal dysfunction, increased level of blood lactate Exclusion Criteria: VA-ECMO after open heart surgery VA-ECMO for the treatment of non-cardiac shock Severe bleeding* Terminal malignancy Irreversible brain damage Pregnancy or lactation The definition of severe bleeding Hemoglobin decrease after VA-ECMO or cannulation site bleeding is not a exclusion criteria Hypovolemic shock due to definite bleeding cause Identifiable bleeding causes: gastrointestinal bleeding, hemothorax, traumatic bleeding, central nervous system hemorrhage, pulmonary hemorrhage

Ages Eligible for Study
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Minimum Age: 19 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Treatment
Allocation: Randomized
Intervention Model: Parallel Assignment
Masking: None (Open Label)


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: Early left atrial septostomy group<br>Early left atrial septostomy group will routinely receive left atrial septostomy within 12 hours after VA-ECMO implantation. | Procedure: Early left atrial septostomy within 12 hours after VA-ECMO implantation<br>* Early left atrial septostomy group will routinely receive left atrial septostomy within 12 hours after VA-ECMO implantation. Left atrial septostomy will be done using percutaneous technique.<br>|
| Active Comparator: Conventional approach group<br>Conventional approach group will receive left atrial septostomy in cases of deleterious effect of increased LVEDP after VA-ECMO implantation, such as refractory pulmonary edema, abnormal opening of aortic valve, left ventricular dilatation, refractory ventricular tachycardia or fibrillation. | Procedure: Selective left atrial septostomy<br>* Left atrial septostomy will be done in cases of deleterious effect of increased LVEDP after VA-ECMO implantation, such as refractory pulmonary edema, abnormal opening of aortic valve, left ventricular dilatation, refractory ventricular tachycardia or fibrillation.<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Cumulative incidence rate of all-cause death | Cumulative incidence rate of all-cause death | Up to 30 days | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Rate of all-cause death or left atrial septostomy in conventional approach group | Rate of all-cause death or left atrial septostomy in conventional approach group | Up to 30 days | 
| Rate of left atrial septostomy in conventional approach group | Rate of left atrial septostomy in conventional approach group | Up to 30 days | 
| Incidence rate of all-cause death during index admission | Incidence rate of all-cause death during index admission | Up to 6 months | 
| Cumulative incidence rate of cardiac death | Cumulative incidence rate of cardiac death | Up to 30 days | 
| Cumulative incidence rate of non-cardiac death | Cumulative incidence rate of non-cardiac death | Up to 30 days | 
| Weaning rate from venoarterial extracorporeal membrane oxygenation during index admission | Weaning rate from venoarterial extracorporeal membrane oxygenation during index admission | Up to 6 months | 
| Rate of disappearance of pulmonary edema on chest X-ray during index admission | Rate of disappearance of pulmonary edema on chest X-ray during index admission | Up to 6 months | 
| Weaning rate from mechanical ventilator during index admission | Weaning rate from mechanical ventilator during index admission | Up to 6 months | 
| Intensive care unit length of stay during index admission | Intensive care unit length of stay during index admission | Up to 6 months | 
| Hospital length of stay | Hospital length of stay | Up to 6 months | 
| Lactate normalization rate | Lactate normalization rate | Up to 30 days | 
| Lactate clearance rate | Lactate clearance rate | Up to 30 days | 
| Rate of renal replacement therapy during index admission | Rate of renal replacement therapy during index admission | Up to 6 months | 
| Rate of limb ischemia during index admission | Rate of limb ischemia during index admission | Up to 6 months | 
| Rate of infection during index admission | Rate of infection during index admission | Up to 6 months | 
| Rate of transient ischemic attack or stroke during index admission | Rate of transient ischemic attack or stroke during index admission | Up to 6 months | 
| Rate of BARC bleeding type 3 or 5 during index admission | Rate of BARC bleeding type 3 or 5 during index admission | Up to 6 months | 
| Rate of bridge to ventricular assist device or heart transplantation during index admission | Rate of bridge to ventricular assist device or heart transplantation during index admission | Up to 6 months | 
| Rate of major vascular injury or cardiac tamponade during left atrial septostomy | Rate of major vascular injury or cardiac tamponade during left atrial septostomy | Up to 30 days | 
| Cumulative incidence rate of all-cause death | Cumulative incidence rate of all-cause death | Up to 12 months | 
| Cumulative incidence rate of cardiac death | Cumulative incidence rate of cardiac death | Up to 12 months | 
| Cumulative incidence rate of non-cardiac death | Cumulative incidence rate of non-cardiac death | Up to 12 months | 
| Re-hospitalization rate due to heart failure | Re-hospitalization rate due to heart failure | Up to 12 months | 
| All-cause death or re-hospitalization rate due to heart failure | All-cause death or re-hospitalization rate due to heart failure | Up to 12 months | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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Extracorporeal membrane oxygenation, Myocardial Infarction, Heart Diseases, Cardiovascular Diseases, Coronary Disease