Left Ventricular Unloading During Extracorporeal Membrane Oxygenation in Patients With Cardiogenic Shock
Left Ventricular Unloading During Extracorporeal Membrane Oxygenation in Patients With Cardiogenic Shock
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DOI：
10.1016/j.jacc.2018.10.085
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发表时间：
2019-02-01
影响因子：
24
通讯作者：
Hibbert, Benjamin
中科院分区：
文献类型：
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作者：
Russo, Juan J.;Aleksova, Natasha;Hibbert, Benjamin
背景：静脉动脉体外膜肺氧合（VA-ECMO）是一种广泛应用于难治性心源性休克患者的机械循环支持形式。这种方式的一个共同的缺点是导致左心室后负荷的增加。ESTA荟萃分析的目的是检查VA-ECMO在成人患者的心源性shock.METHODS左心室卸载策略的有效性和安全性进行了系统的研究检查VA-ECMO在Medline，EMBASE，和科克伦图书馆的左心室卸载。主要结局为全因死亡率。次要结果包括肢体缺血、出血、需要肾脏替代治疗、多器官功能衰竭、卒中或短暂性脑缺血发作和溶血。总共纳入了3，997例患者的结局，其中1，696例（42%）在VA-ECMO期间接受了伴随的左心室卸载策略（主动脉内球囊反搏91.7%，经皮心室辅助装置5.5%，肺静脉或经间隔左心房插管2.8%）。总队列中有2，412例死亡（60%）。在VA-ECMO中，左心室去负荷患者的死亡率（54%）低于无左心室去负荷患者（65%）（风险比：0.79; 95%置信区间：0.72 - 0.87; p < 0.00001）。左室去负荷VA-ECMO患者溶血率较高。否则，次要结果是没有明显不同的患者与VA-ECMO与左心室unloading.CONCLUSIONS在观察性研究中，左心室卸载与VA-ECMO治疗心源性休克的成人患者死亡率降低。在缺乏前瞻性随机数据的情况下，可考虑对适当选择的接受VA-ECMO支持的患者进行左心室去负荷。(c)2019年，任作家。由爱思唯尔代表美国心脏病学会基金会出版。这是一个在CC BY-NC-ND许可证下的开放获取文章（http：//creativecommons.org/licenses/by-nc-nd/4.0/）。
BACKGROUND Venoarterial extracorporeal membrane oxygenation (VA-ECMO) is a widely used form of mechanical circulatory support in patients with refractory cardiogenic shock. A common drawback of this modality is a resultant increase in left ventricular afterload.OBJECTIVES The purpose of this meta-analysis was to examine the efficacy and safety of left ventricular unloading strategies during VA-ECMO in adult patients with cardiogenic shock.METHODS The authors performed a systematic search of studies examining left ventricular unloading during VA-ECMO in Medline, EMBASE, and the Cochrane library. The primary outcome was all-cause mortality. Secondary outcomes included limb ischemia, bleeding, need for renal replacement therapy, multiorgan failure, stroke or transient ischemic attack, and hemolysis.RESULTS Of 2,221 publications identified, 17 observational studies met the inclusion criteria. In total, outcomes in 3,997 patients were included with 1,696 (42%) receiving a concomitant left ventricular unloading strategy while on VA-ECMO (intra-aortic balloon pump 91.7%, percutaneous ventricular assist device 5.5%, pulmonary vein or transseptal left atrial cannulation 2.8%). There were 2,412 deaths (60%) in the total cohort. Mortality was lower in patients with (54%) versus without (65%) left ventricular unloading while on VA-ECMO (risk ratio: 0.79; 95% confidence interval: 0.72 to 0.87; p < 0.00001). Hemolysis was higher in patients who underwent VA-ECMO with left ventricular unloading. Otherwise, secondary outcomes were not demonstrably different in patients treated with VA-ECMO with versus without left ventricular unloading.CONCLUSIONS In observational studies, left ventricular unloading was associated with decreased mortality in adult patients with cardiogenic shock treated with VA-ECMO. In the absence of prospective randomized data, left ventricular unloading may be considered for appropriately selected patients undergoing VA-ECMO support. (c) 2019 The Authors. Published by Elsevier on behalf of the American College of Cardiology Foundation. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).