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Schrage, Benedikt; Becher, Peter Moritz; Bernhardt, Alexander; Bezerra, Hiram; Blankenberg, Stefan; Brunner, Stefan; Colson, Pascal; Cudemus Deseda, Gaston; Dabboura, Salim; Eckner, Dennis; Eden, Matthias; Eitel, Ingo; Frank, Derk; Frey, Norbert; Funamoto, Masaki; Gossling, Alina; Graf, Tobias; Hagl, Christian; Kirchhof, Paulus; Kupka, Danny; Landmesser, Ulf; Lipinski, Jerry; Lopes, Mathew; Majunke, Nicolas; Maniuc, Octavian; McGrath, Daniel; Mobius-Winkler, Sven; Morrow, David A.; Mourad, Marc; Noel, Curt; Nordbeck, Peter; Orban, Martin; Pappalardo, Federico; Patel, Sandeep M.; Pauschinger, Matthias; Pazzanese, Vittorio; Reichenspurner, Hermann; Sandri, Marcus; Schulze, P. Christian; H.G. Schwinger, Robert; Sinning, Jan-Malte; Aksoy, Adem; Skurk, Carsten; Szczanowicz, Lukasz; Thiele, Holger; Tietz, Franziska; Varshney, Anubodh; Wechsler, Lukas and Westermann, Dirk (2020): Left Ventricular Unloading Is Associated With Lower Mortality in Patients With Cardiogenic Shock Treated With Venoarterial Extracorporeal Membrane Oxygenation Results From an International, Multicenter Cohort Study. In: Circulation, Vol. 142, No. 22: pp. 2095-2106

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Background: Venoarterial extracorporeal membrane oxygenation (VA-ECMO) is increasingly used to treat cardiogenic shock. However, VA-ECMO might hamper myocardial recovery. The Impella unloads the left ventricle. This study aimed to evaluate whether left ventricular unloading in patients with cardiogenic shock treated with VA-ECMO was associated with lower mortality. Methods: Data from 686 consecutive patients with cardiogenic shock treated with VA-ECMO with or without left ventricular unloading using an Impella at 16 tertiary care centers in 4 countries were collected. The association between left ventricular unloading and 30-day mortality was assessed by Cox regression models in a 1:1 propensity score-matched cohort. Results: Left ventricular unloading was used in 337 of the 686 patients (49%). After matching, 255 patients with left ventricular unloading were compared with 255 patients without left ventricular unloading. In the matched cohort, left ventricular unloading was associated with lower 30-day mortality (hazard ratio, 0.79 [95% CI, 0.63-0.98];P=0.03) without differences in various subgroups. Complications occurred more frequently in patients with left ventricular unloading: severe bleeding in 98 (38.4%) versus 45 (17.9%), access site-related ischemia in 55 (21.6%) versus 31 (12.3%), abdominal compartment in 23 (9.4%) versus 9 (3.7%), and renal replacement therapy in 148 (58.5%) versus 99 (39.1%). Conclusions: In this international, multicenter cohort study, left ventricular unloading was associated with lower mortality in patients with cardiogenic shock treated with VA-ECMO, despite higher complication rates. These findings support use of left ventricular unloading in patients with cardiogenic shock treated with VA-ECMO and call for further validation, ideally in a randomized, controlled trial.

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