Predictors of Mortality in Veno-Arterial Extracorporeal Membrane Oxygenation Regardless of Early Left Ventricular Unloading: A National Experience

<h3>Objective </h3><p dir="ltr">The use of Intra-Aortic Balloon Pump (IABP) has been suggested to unload the left ventricle (LV) while on Veno-Arterial Extracorporeal Membrane Oxygenation (VA-ECMO) for cardiogenic shock (CS), leading to possibly improved in-hospital mortality. However, the predictors of mortality on dual mechanical circulatory support (MCS) have not yet been evaluated, especially in real-world clinical settings. Therefore, we conducted a case-control study to determine the rate of all-cause mortality associated with VA-ECMO use regardless of LV unloading, and with early LV unloading in the setting of CS, and to identify the predictors of mortality associated with VA-ECMO, and with concurrent early LV unloading. </p><h3>Design </h3><p dir="ltr">Retrospective observational case-control study. </p><h3>Setting </h3><p dir="ltr">National tertiary cardiology center. </p><h3>Participants </h3><p dir="ltr">All patients with CS requiring VA-ECMO cannulation during the index admission between 1/06/2016 and 1/06/2022. </p><h3>Intervention</h3><p dir="ltr">VA-ECMO with or without IABP.</p><h3>Measurements and Main Results </h3><p dir="ltr">Patient- and disease-related characteristics associated with in-hospital 30-day mortality following VA-ECMO with and without IABP support were assessed using multivariate logistic regression. Results were presented as odds ratio (OR), and a P-value <0.05 indicated statistical significance. A total of 110 patients were included. Most of the patients were male (90%) with a mean age of 53±11 years. Around 67% were Asian. The majority of patients were admitted with ST-elevation myocardial infarction (87%) with 26% presenting with left main (LM) disease. In-hospital 30-day mortality occurred in 42.7% among those who received VA-ECMO support regardless of IABP use, while it was 46.9% among those receiving early LV unloading with IABP. The significant positive predictors of mortality with VA-ECMO regardless of IABP in CS were CPR > 20 minutes (aOR 14.74, 95% CI 2.02-107.41; p-value= 0.008), older age (i.e., greater than 55 years) and LM disease of more than 50% stenosis were associated with a fourfold increase in the odds of mortality while on VA-ECMO. Whereas CPR > 20 minutes (aOR 12.45, 95% CI 1.79-86.36; <i>p</i>-value= 0.011) was the only significant positive predictor of mortality with VA-ECMO and IABP. </p><h3>Conclusion </h3><p dir="ltr">Mortality rate in CS requiring VA-ECMO regardless of IABP use remains high. However, only one predictor (i.e. prolonged CPR) was found to increase the likelihood of 30-day mortality with early LV unloading, suggesting that concomitant IABP use might minimize the effect of mortality predictors.</p><h2>Other Information</h2><p dir="ltr">Published in: Journal of Cardiothoracic and Vascular Anesthesia<br>License: <a href="http://creativecommons.org/licenses/by/4.0/" target="_blank">http://creativecommons.org/licenses/by/4.0/</a><br>See article on publisher's website: <a href="https://dx.doi.org/10.1053/j.jvca.2025.01.013" target="_blank">https://dx.doi.org/10.1053/j.jvca.2025.01.013</a></p>