VA-ECMO for infarct-related cardiogenic shock

In a study by Uwe Zeymer and colleagues,1Zeymer U Freund A Hochadel M et al.Venoarterial extracorporeal membrane oxygenation in patients with infarct-related cardiogenic shock: an individual patient data meta-analysis of randomised trials.Lancet. 2023; 402: 1338-1346Summary Full Text Full Text PDF PubMed Scopus (45) Google Scholar it was observed that for patients with infarct-related cardiogenic shock, venoarterial extracorporeal membrane oxygenation (VA-ECMO) did not reduce the number of all-cause deaths at 30 days compared with medical treatment alone. Moreover, there was a marked increase in major bleeding and vascular complications. Based on these research findings, the authors concluded that ECMO is not universally appropriate for every patient, with which we concur. Beyond the patient's underlying medical condition, the timing of ECMO deployment plays a pivotal role, as highlighted by the authors in the Discussion of their Article.1Zeymer U Freund A Hochadel M et al.Venoarterial extracorporeal membrane oxygenation in patients with infarct-related cardiogenic shock: an individual patient data meta-analysis of randomised trials.Lancet. 2023; 402: 1338-1346Summary Full Text Full Text PDF PubMed Scopus (45) Google Scholar Although the researchers juxtaposed the outcomes of ECMO administration before and during percutaneous coronary intervention (PCI), we perceive specific shortcomings in their methodological approach. Considering that this study is rooted in an individual patient data meta-analysis, a more nuanced approach would involve pairing patients who underwent ECMO before PCI with their counterparts who received it during PCI, rather than broadly contrasting both patient sets. In a real-world clinical setting, those who get ECMO before PCI typically need life support, suggesting a more severe health state. As such, drawing a more definitive conclusion necessitates analysis after aligning these patients with those with comparable conditions who were on ECMO during PCI. Several studies have shown that VA-ECMO implementation before PCI improves the chance of survival in patients with acute myocardial infarction.2Kagawa E Dote K Kato M et al.Should we emergently revascularize occluded coronaries for cardiac arrest?: rapid-response extracorporeal membrane oxygenation and intra-arrest percutaneous coronary intervention.Circulation. 2012; 126: 1605-1613Crossref PubMed Scopus (194) Google Scholar, 3Tsao N-W Shih C-M Yeh J-S et al.Extracorporeal membrane oxygenation-assisted primary percutaneous coronary intervention may improve survival of patients with acute myocardial infarction complicated by profound cardiogenic shock.J Crit Care. 2012; 27: 530Crossref PubMed Scopus (116) Google Scholar, 4Huang C-C Hsu J-C Wu Y-W et al.Implementation of extracorporeal membrane oxygenation before primary percutaneous coronary intervention may improve the survival of patients with ST-segment elevation myocardial infarction and refractory cardiogenic shock.Int J Cardiol. 2018; 269: 45-50Summary Full Text Full Text PDF PubMed Scopus (38) Google Scholar Although the idea of time-to-unload appeared counterintuitive in pigs with myocardial infarction and cardiogenic shock, it was evident that initiation of VA-ECMO right after shock slowed down the left ventricular end-diastolic pressure (LVEDP) elevation and caused a faster recovery of pumping function.5Briceno N Annamalai SK Reyelt L et al.Left ventricular unloading increases the coronary collateral flow index before reperfusion and reduces infarct size in a swine model of acute myocardial infarction.J Am Heart Assoc. 2019; 8e013586 Crossref PubMed Scopus (32) Google Scholar It was also found that the LVEDP was lower in the VA-ECMO-supported pigs than in the control group, and it returned to baseline 24 h after the onset of shock.5Briceno N Annamalai SK Reyelt L et al.Left ventricular unloading increases the coronary collateral flow index before reperfusion and reduces infarct size in a swine model of acute myocardial infarction.J Am Heart Assoc. 2019; 8e013586 Crossref PubMed Scopus (32) Google Scholar To conclude, the efficacy of VA-ECMO for patients with infarct-related cardiogenic shock still needs further evaluation. I declare no competing interests. Venoarterial extracorporeal membrane oxygenation in patients with infarct-related cardiogenic shock: an individual patient data meta-analysis of randomised trialsVA-ECMO did not reduce 30-day death rate compared with medical therapy alone in patients with infarct-related cardiogenic shock, and an increase in major bleeding and vascular complications was observed. A careful review of the indication for VA-ECMO in this setting is warranted. Full-Text PDF