Unloading strategies in venoarterial extracorporeal membrane oxygenation: Insights from a contemporary cohort

Objective: Venoarterial extracorporeal membrane oxygenation (VA-ECMO) provides temporary support in refractory cardiogenic shock but can exacerbate left ventricular (LV) overload.LV unloading strategies, such as intra-aortic balloon pump (IABP) and microaxial flow pumps (e.g., Impella), have been proposed to mitigate these effects, but their survival benefit remains uncertain.This study aimed to assess the impact of invasive LV unloading strategies in cardiogenic shock patients supported with VA-ECMO and signs of LV overload.Methods: We conducted a retrospective study of patients with refractory cardiogenic shock treated with VA-ECMO at a single tertiary center.The primary endpoint was 30-day survival.Outcomes were compared between patients who underwent invasive LV unloading and those managed without unloading, using logistic regression and Kaplan-Meier analysis.Results: A total of 86 patients were included [mean age 54.5 (11.8) years; 62% male] and LV unloading was performed in 34 patients (39.5%).The overall 30-day survival rate was 41% (95% CI, 30-55%), with no significant difference between the unloading group (31%, 95% CI 19-53%) and the non-unloading group (50%, 95% CI 35-70%) (p = 0.11).LV unloading was associated with a hazard ratio for 30-day mortality of 1.64 (95% CI, 0.30-1.68),and 1.21 (95% CI, 0.64-2.28)after adjustment for SCAI stage of shock.Predictors of mortality included higher baseline lactate (HR 1.09, 95% CI, 1.00-1.19),male gender (HR 2.99, 95% CI, 1.29-6.98)and SCAI E (HR 2.24; 95% CI, 1.12-4.47).Airway bleeding was more frequent in the unloading group (20.6% vs. 3.8%; p = 0.0369).Conclusion: LV unloading was not associated with improved 30-day survival in VA-ECMO-treated patients with refractory cardiogenic shock, but may offer potential benefit in selected high-risk patients.