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Survival after refractory cardiogenic shock is comparable in patients with Impella and veno-arterial extracorporeal membrane oxygenation when adjusted for SAVE score
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Thoracic Surgery.
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Thoracic Surgery.
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Thoracic Surgery.
2019 (English)In: European heart journal. Acute cardiovascular care., ISSN 2048-8726, Vol. 8, no 4, p. 329-337Article in journal (Refereed) Published
Abstract [en]

Objectives: Survival after different short-term mechanical circulatory support is difficult to compare because various systems are used and patient disease severity is most often not adjusted for. This study compares the outcome after the use of Impella and veno-arterial extracorporeal membrane oxygenation (VA-ECMO) in refractory cardiogenic shock, adjusted for disease severity through the survival after the VA-ECMO (SAVE) score.Methods: Patients with refractory shock treated with either VA-ECMO or Impella between January 2003 and August 2015 were included. Data were analysed to assess short and long-term survival and complications. The SAVE score was calculated for the two groups and outcome was compared adjusted for the SAVE score.Results: There was no difference between VA-ECMO patients (n=46) and Impella patients (n=48) in mean age or renal failure. ECMO patients were more often intubated and had lower diastolic blood pressure at device implantation. ECMO patients had a lower SAVE score (–0.4 (6.5)) compared to Impella patients (4.1 (5.4)). There was no difference in intensive care unit survival between ECMO patients 65% (52–80) or Impella patients 63% (55–79), or long-term survival between groups. When stratified into worse (III–IV) or better SAVE class (I–II) there was no difference in survival between the groups.Conclusions: Short and long-term survival is not measurably different among patients treated with Impella or VA-ECMO due to refractory cardiogenic shock, after adjustment for disease severity through the SAVE score.

Place, publisher, year, edition, pages
2019. Vol. 8, no 4, p. 329-337
National Category
Cardiac and Cardiovascular Systems
Identifiers
URN: urn:nbn:se:uu:diva-347426DOI: 10.1177/2048872618799745ISI: 000471762200005OAI: oai:DiVA.org:uu-347426DiVA, id: diva2:1194385
Available from: 2018-04-02 Created: 2018-04-02 Last updated: 2019-08-05Bibliographically approved
In thesis
1. Mechanical Circulatory Support in Left Ventricular Heart Failure
Open this publication in new window or tab >>Mechanical Circulatory Support in Left Ventricular Heart Failure
2018 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Short-term mechanical circulatory support (MCS) with ventricular assist devices or veno-arterial extracorporeal membrane oxygenation (VA ECMO) has become the standard treatment in patients with cardiogenic shock unresponsive to pharmacological treatment. However, the haemodynamic effects of these devices are not yet fully described, nor are their effects on ventricular function and myocardial recovery.

The aims of this thesis are to increase knowledge of the haemodynamic changes during MCS in different settings and to provide new insights into how MCS therapy should be guided in the specific patient.

In Studies I and II, we developed experimental animal models to investigate the effect of VA ECMO on left ventricular (LV) performance and size of myocardial infarction in different cannulation strategies. In Study I, we found that the LV performance was negatively affected by VA ECMO in both centrally and peripherally cannulated animals. In Study II, we specifically studied the effect of VA ECMO with and without the addition of LV drainage on the size of experimentally induced myocardial infarction. The results showed that active LV decompression had no effect on infarct size in the acute setting.

Studies III and IV are retrospective studies on patients in cardiogenic shock treated with short-term mechanical support with either Impella® (Studies III and IV) or VA ECMO (Study IV). In Study IV, we concluded that treatment with Impella® has excellent effects on haemodynamic parameters and an acceptable mortality and complication rate. The studied pre-implantation patient parameters did not significantly affect outcome. In Study IV, we compared the outcome of patients treated with Impella® with those treated with VA ECMO. After adjustment for pre-implantation patient status, as defined by SAVE score, no difference in short- or long-term mortality was seen between the two groups.

In conclusion, VA ECMO, whether central or peripheral, negatively affects the LV, and the addition of a LV drain has no effect on infarct size in these experimental models. Both Impella® and VA ECMO offer good haemodynamic results with acceptable mortality and complication rates in patients with refractory cardiogenic shock. When adjusted for the SAVE score, the outcomes of both treatment modalities are comparable.

Place, publisher, year, edition, pages
Uppsala: Acta Universitatis Upsaliensis, 2018. p. 68
Series
Digital Comprehensive Summaries of Uppsala Dissertations from the Faculty of Medicine, ISSN 1651-6206 ; 1464
Keywords
Mechanical Circulatory Support, Left Ventricular Heart Failure, Left Ventricular Assist Device, Extracorporeal Membrane Oxygenation, ECMO
National Category
Surgery Cardiac and Cardiovascular Systems
Research subject
Thorax Surgery
Identifiers
urn:nbn:se:uu:diva-347427 (URN)978-91-513-0330-7 (ISBN)
Public defence
2018-06-06, Enghoffsalen, Ingång 50 bv, Akademiska sjukhuset, Uppsala, 09:15 (Swedish)
Opponent
Supervisors
Available from: 2018-05-14 Created: 2018-04-12 Last updated: 2018-10-08

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