Luca Baldetti1, Mario Gramegna2, Alessandro Beneduce3, Francesco Melillo4, Francesco Moroni3, Francesco Calvo5, Giulio Melisurgo5, Silvia Ajello5, Evgeny Fominskiy5, Federico Pappalardo5, Anna Mara Scandroglio5. 1. Cardiac Surgery Intensive Care Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy. Electronic address: luca.baldetti@gmail.com. 2. Coronary Intensive Care Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy. 3. Unit of Cardiovascular Interventions, IRCCS San Raffaele Scientific Institute, Milan, Italy Unit. 4. Unit of Echocardiography, IRCCS San Raffaele Scientific Institute, Milan, Italy. 5. Cardiac Surgery Intensive Care Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy.
Abstract
BACKGROUND: Left ventricle (LV) unloading during VenoArterial ExtraCorporeal Membrane Oxygenation (VA-ECMO) reduces the risk of LV distention, stagnation and pulmonary congestion resulting from the increased afterload. Lacking direct comparisons between unloading strategies we used network meta-analysis to indirectly compare different unloading approaches. METHODS: A literature research was performed to include all studies on VA-ECMO reporting data on mechanical LV unloading. The pre-specified outcome was in-hospital death. RESULTS: Literature search identified 389 studies: 16 were included in the analysis (3930 patients). Two strategies of mechanical LV unloading were compared: afterload reduction (IABP) and preload reduction (Impella pump, right upper pulmonary/trans-septal catheters, LV surgical vents). Any LV unloading strategy was associated with mortality reduction with overall OR = 0.54; 95% CI 0.42-0.70; p < .001. Targeting afterload was associated with reduced mortality (OR = 0.61 95% CI 0.46-0.81; p < .001; I2 = 61%), as targeting preload (OR = 0.34 95% CI 0.21-0.55; p < .001; I2 = 0%). Significant between group difference was observed (p = .04): to further explore this we performed a network meta-analysis. Indirect comparisons between afterload and preload reduction were estimated. Any unloading technique was confirmed better than none but preload targeting resulted better than afterload targeting. CONCLUSION: Any unloading strategy in VA-ECMO patients was associated with lower mortality as compared to no-unloading. Preload reduction strategies resulted superior to afterload reduction.
BACKGROUND: Left ventricle (LV) unloading during VenoArterial ExtraCorporeal Membrane Oxygenation (VA-ECMO) reduces the risk of LV distention, stagnation and pulmonary congestion resulting from the increased afterload. Lacking direct comparisons between unloading strategies we used network meta-analysis to indirectly compare different unloading approaches. METHODS: A literature research was performed to include all studies on VA-ECMO reporting data on mechanical LV unloading. The pre-specified outcome was in-hospital death. RESULTS: Literature search identified 389 studies: 16 were included in the analysis (3930 patients). Two strategies of mechanical LV unloading were compared: afterload reduction (IABP) and preload reduction (Impella pump, right upper pulmonary/trans-septal catheters, LV surgical vents). Any LV unloading strategy was associated with mortality reduction with overall OR = 0.54; 95% CI 0.42-0.70; p < .001. Targeting afterload was associated with reduced mortality (OR = 0.61 95% CI 0.46-0.81; p < .001; I2 = 61%), as targeting preload (OR = 0.34 95% CI 0.21-0.55; p < .001; I2 = 0%). Significant between group difference was observed (p = .04): to further explore this we performed a network meta-analysis. Indirect comparisons between afterload and preload reduction were estimated. Any unloading technique was confirmed better than none but preload targeting resulted better than afterload targeting. CONCLUSION: Any unloading strategy in VA-ECMO patients was associated with lower mortality as compared to no-unloading. Preload reduction strategies resulted superior to afterload reduction.
Authors: Benedikt Schrage; Peter Moritz Becher; Alexander Bernhardt; Hiram Bezerra; Stefan Blankenberg; Stefan Brunner; Pascal Colson; Gaston Cudemus Deseda; Salim Dabboura; Dennis Eckner; Matthias Eden; Ingo Eitel; Derk Frank; Norbert Frey; Masaki Funamoto; Alina Goßling; Tobias Graf; Christian Hagl; Paulus Kirchhof; Danny Kupka; Ulf Landmesser; Jerry Lipinski; Mathew Lopes; Nicolas Majunke; Octavian Maniuc; Daniel McGrath; Sven Möbius-Winkler; David A Morrow; Marc Mourad; Curt Noel; Peter Nordbeck; Martin Orban; Federico Pappalardo; Sandeep M Patel; Matthias Pauschinger; Vittorio Pazzanese; Hermann Reichenspurner; Marcus Sandri; P Christian Schulze; Robert H G Schwinger; Jan-Malte Sinning; Adem Aksoy; Carsten Skurk; Lukasz Szczanowicz; Holger Thiele; Franziska Tietz; Anubodh Varshney; Lukas Wechsler; Dirk Westermann Journal: Circulation Date: 2020-10-09 Impact factor: 29.690
Authors: Luca Baldetti; Alessandro Beneduce; Antonio Boccellino; Matteo Pagnesi; Giuseppe Barone; Guglielmo Gallone; Antonio Napolano; Mario Gramegna; Francesco Calvo; Vittorio Pazzanese; Stefania Sacchi; Alberto M Cappelletti Journal: Catheter Cardiovasc Interv Date: 2022-04-14 Impact factor: 2.585
Authors: Jesse R Kimman; Nicolas M Van Mieghem; Henrik Endeman; Jasper J Brugts; Alina A Constantinescu; Olivier C Manintveld; Eric A Dubois; Corstiaan A den Uil Journal: Curr Heart Fail Rep Date: 2020-10