Early Left ventricular unLoading by Impella CP (ECMELLA) or intra-aortic balloon Pump for cardiogenic Shock in patients on VA-ECMO

Objectif(s) de la recherche et intérêt pour la santé publique

Finalité de l'étude

Objectifs poursuivis

Domaines médicaux investigués

Bénéfices attendus

The expected benefits are:
- For future patient: By comparing two techniques of early left ventricular unloading after VA-ECMO placement, we aim to identify the method that provides the best balance of benefits and risks for the patient. Determining the superior technique is crucial for optimizing patient outcomes.

Indeed, providing early LV unloading can reduce the detrimental effects of VA-ECMO by decreasing the parietal stress imposed by VA-ECMO's retrograde flow, thereby promoting subendocardial perfusion and cardiac recovery. Efficient LV unloading can also reduce the use of catecholamines, which are drugs known to increase myocardial oxygen consumption. These metabolic improvements in the myocardium can accelerate its functional recovery and enhance the chances of successfully weaning from VA-ECMO.

Furthermore, the reduction in the duration of VA-ECMO support may decrease the risk of associated hemorrhagic or thromboembolic complications, which significantly contribute to patient morbidity. By comparing these two LV unloading techniques, we aim to identify which method offers superior myocardial protection, thus reducing the extent of myocardial damage and decreasing the incidence or severity of long-term residual heart failure. This comparison will elucidate the best approach to balance the benefits and risks, ultimately improving patient prognosis and informing future clinical guidelines.

- For public health:
Comparing the two techniques for early left ventricular unloading in cardiogenic shock is crucial for identifying the most effective method to enhance myocardial recovery. Early LV unloading can significantly improve the chances of myocardial recovery, potentially reducing the need for heart transplantation or emergency LVAD implantation. In the context of organ shortages, successful weaning from post-infarction VA-ECMO directly saves organs for other candidates in need. Additionally, avoiding immediate LVAD implantation alleviates the inherent difficulties and costs associated with emergency procedures post-cardiogenic shock, as well as the burdensome long-term management required for LVAD patients.

Post-cardiogenic shock, the incidence of severe chronic heart failure with reduced ejection fraction is notably high. By optimizing residual heart function, we may decrease the incidence of chronic heart failure, reduce recurrent hospitalizations due to heart failure decompensation, and improve patients' quality of life. Thus, this study's comparison of the two LV unloading techniques is vital for determining the best strategy to maximize patient outcomes and streamline future clinical practice.

Inclusion criteria: Adult patients (>18 years) admitted for cardiogenic shock supported by ECMO+ IABP or ECMELLA between January 1, 2010, and December 31, 2023

Exclusion criteria:
- extra-corporeal CardioPulmonary Resuscitation (eCPR)
- Cardiogenic shock with previous Continuous cardiopulmonary resuscitation (CPR) > 30 minutes
- Acute irreversible neurological pathology
- Known severe chronic cardiomyopathy (LVEF <25%) or awaiting transplantation or LVAD implantation
- Contraindication to the implantation of an Impella CP or IABP
- Mechanical complications of myocardial infarction
- Moribund patient (SAPS II > 90)
- Severe chronic renal or hepatic failure
Age < 18 years