Strategies of left ventricular unloading during VA-ECMO support: a network meta-analysis.
patients undergoing VA-ECMO
mechanical LV unloading
afterload reduction (IABP) vs. preload reduction (Impella pump, right upper pulmonary/trans-septal catheters, LV surgical vents)
in-hospital death
Abstract
Left ventricle (LV) unloading during VenoArterial ExtraCorporeal Membrane Oxygenation (VA-ECMO) reduces the risk of LV distention, stagnation and pulmonary congestion resulting from the increased afterload. Lacking direct comparisons between unloading strategies we used network meta-analysis to indirectly compare different unloading approaches. A literature research was performed to include all studies on VA-ECMO reporting data on mechanical LV unloading. The pre-specified outcome was in-hospital death. Literature search identified 389 studies: 16 were included in the analysis (3930 patients). Two strategies of mechanical LV unloading were compared: afterload reduction (IABP) and preload reduction (Impella pump, right upper pulmonary/trans-septal catheters, LV surgical vents). Any LV unloading strategy was associated with mortality reduction with overall OR = 0.54; 95% CI 0.42-0.70; p < .001. Targeting afterload was associated with reduced mortality (OR = 0.61 95% CI 0.46-0.81; p < .001; I Any unloading strategy in VA-ECMO patients was associated with lower mortality as compared to no-unloading. Preload reduction strategies resulted superior to afterload reduction.