Interventional procedure overview of venoarterial extracorporeal membrane oxygenation (VA ECMO) for acute heart failure

Briglio SE, Khanduja V, Lothan JD et al. (2024) Fulminant myocarditis and venoarterial extracorporeal membrane oxygenation: a systematic review. Cureus 16(2): e54711

Systematic review

n=425 11 studies

Regarding short-term outcomes, one-year post-hospital survival rate ranged from 57.1% to 78% at discharge.

For long-term health and survival, studies that recorded long-term survival ranged from 65% to 94.1%.

No meta-analysis.

Burgos LM, Seoane L, Diez M et al. (2023) Multiparameters associated to successful weaning from VA ECMO in adult patients with cardiogenic shock or cardiac arrest: Systematic review and meta-analysis. Annals of cardiac anaesthesia 26(1): 4-11

Systematic review and meta-analysis

n=653 11 studies

Follow-up: weaning, hospital discharge

Pooled VA ECMO successful weaning [patient survives 48 hours after ECMO explantation] was 45% (95% CI: 39 to 50%, I² 7%) and in‑hospital mortality rate was

46.6% (95% CI: 33 to 60%; I² 36%).

Larger, more comprehensive systematic literature reviews and meta-analysis included.

5/11 studies in this SLR were included within the SLRs in the key evidence.

Carroll BJ, Shah RV, Murthy V et al. (2015) Clinical features and outcomes in adults with cardiogenic shock supported by extracorporeal membrane oxygenation. The American journal of cardiology 116(10): 1624-30

Single centre retrospective study, US

n=123 (26 postcardiotomy [21%])

Follow-up: In-hospital

More recent studies included.

Cheng R, Hachamovitch R, Kittleson M et al. (2014) Clinical outcomes in fulminant myocarditis requiring extracorporeal membrane oxygenation: a weighted meta-analysis of 170 patients. Journal of cardiac failure 20(6): 400-6

Systematic review and meta-analysis

n=170

6 studies

The pooled estimate rate of survival to hospital discharge was 66.9% (95% CI 59.4% to 73.7%).

More than two-thirds of patients with FM and either cardiogenic shock and/or cardiac arrest

survive to hospital discharge with ECMO.

More recent systematic reviews and meta-analyses included.

4/6 studies in this SLR were included within the SLRs in the key evidence.

Cheng R, Hachamovitch R, Kittleson M et al. (2014) Complications of extracorporeal membrane oxygenation for treatment of cardiogenic shock and cardiac arrest: A meta-analysis of 1,866 adult patients. Annals of Thoracic Surgery 97(2): 610-616

Systematic review and meta-analysis

n=1,866 20 studies

Follow-up: Hospital discharge

Seventeen studies reported survival to hospital discharge, range: 20.8% to 65.4%.

More recent systematic reviews and meta-analyses included.

7/20 studies in this SLR were included within the SLRs in the key evidence.

Danial P, Olivier M-E, Brechot N et al. (2023) Association between shock etiology and 5-year outcomes after venoarterial extracorporeal membrane oxygenation. Journal of the American College of Cardiology 81(9): 897-909

Single centre retrospective study, US

n=1,253

Follow-up: in-hospital, 5 years

In-hospital and 5-year survival rates were, respectively, 73.3% and 57.3% for primary graft failure, 58.6% and 54.0% for drug overdose, 53.2% and 45.3% for dilated cardiomyopathy, 51.6% and 50.0% for arrhythmic storm, 46.8% and 38.3% for massive pulmonary embolism, 44.4% and 42.4% for sepsis-induced cardiogenic shock, 37.9% and 32.9% for fulminant myocarditis, 37.3% and 31.5% for acute myocardial infarction, 34.6% and 33.3% for postcardiotomy excluding primary graft failure, 25.7% and 22.8% for other/unknown aetiology, and 11.1% and 0.0% for refractory vasoplegia shock.

Larger, more comprehensive systematic literature reviews and meta-analysis included.

Dangers L, Brechot N, Schmidt M et al. (2017) Extracorporeal membrane oxygenation for acute decompensated heart failure. Critical Care Medicine 45(8): 1359-1366

Single centre retrospective study, France

n=105

Follow-up: 1 year

Survival at 1 year was 42%, with 44% of the cohort receiving heart transplantation. Survival was considerably lower (17%) in people with a high pre-ECMO SOFA score (≥14), than those with SOFA score less than 7 (52%).

More recent studies from broader regions included.

Flecher E, Anselmi A, Corbineau H et al. (2014) Current aspects of extracorporeal membrane oxygenation in a tertiary referral centre: determinants of survival at follow-up. European Journal of Cardio-thoracic Surgery: official journal of the European Association for Cardio-thoracic Surgery 46(4): 665-671

Single centre retrospective study, France

n=325 (postcardiotomy 29%)

Follow-up: mean 84 days (SD: 86)

Overall in the VA group, weaning rates were 59%, survival at 30^th post implantation day was 44% and survival at the end of the follow-up was 41%.

More recent studies with outcomes split by aetiologies were included.

Hernandez-Montfort JA, Xie R, Ton VK et al. (2020) Longitudinal impact of temporary mechanical circulatory support on durable ventricular assist device outcomes: An IMACS registry propensity matched analysis. The Journal of Heart and Lung Transplantation: the official publication of the International Society for Heart Transplantation 39(2): 145-156

Retrospective INTERMACS registry study.

n=13,813

Follow-up: 48 months

INTERMACS Profile 1 to 3 patients with pre-implant ECMO had 82% survival at 1 month and 44% at 48 months.

22% people requiring ECMO needed biventricular support after dVAD.

Registry studies with more relevant outcomes were included.

Lackermair K, Brunner S, Orban M et al. (2021) Outcome of patients treated with extracorporeal life support in cardiogenic shock complicating acute myocardial infarction: 1-year result from the ECLS-Shock study. Clinical Research in Cardiology: official journal of the German Cardiac Society 110(9): 1412-1420

Randomised controlled trial

n=42

Follow-up: 12 months

12-month all-cause mortality was numerically lower, and favourable neurological outcome numerically higher in the ECLS arm compared to the no ECLS arm.

Pilot study, superseded by Thiele, 2023 ECLS-SHOCK study

Lee JH, Choi N, Kim YJ et al. (2021) Use of extracorporeal life support for heart transplantation: Key factors to improve outcome. Journal of Clinical Medicine 10(12): 2542

Single centre retrospective study, Korea.

n=257 (100 ECLS)

Follow-up: 30 days and 12 months after HTx

The 30-day mortality rate was 3.9% (9.2% in peripheral ECLS, 2.9% in central ECLS, and 1.9% in non-ECLS). The use of ECLS was not an independent predictor of 30-day and 1-year mortality (p = 0.248 and p = 0.882, respectively).

Larger, more comprehensive systematic literature reviews and meta-analysis included.

Lorusso R, Gelsomino S, Parise O et al. (2017) Venoarterial extracorporeal membrane oxygenation for refractory cardiogenic shock in elderly patients: trends in application and outcome from the Extracorporeal Life Support Organization (ELSO) Registry. Annals of Thoracic Surgery 104(1): 62-69

Retrospective ELSO registry study.

n=5,408 (735 ≥70 years)

Follow-up: hospital discharge

Survival to hospital discharge for the entire adult cohort was 41.4%, with 30.5% (224/735) in the elderly patient group and 43.1% (2,016 of 4,673) in the younger patient group (p<0.001). Elderly patients had a higher rate of multiorgan failure. At multivariable analysis age represented an independent negative predictor of in-hospital survival.

Larger, more comprehensive registry studies were included.

Loungani RS, Fudim M, Ranney D et al. (2021) Contemporary use of venoarterial extracorporeal membrane oxygenation: insights from the multicenter RESCUE registry. Journal of cardiac failure 27(3): 327-337

Retrospective RESCUE registry study.

n=723

Follow-up: hospital discharge

40% of the cohort survived to discharge,

Mortality for ECMO following heart transplant (42.4%) and cardiomyopathy (59.3%) was less than those receiving ECMO for postcardiotomy CS (64%), AMI (60.7%).

Larger, more comprehensive registry studies were included.

Loyaga-Rendon RY, Boeve T, Tallaj J et al. (2020). Extracorporeal membrane oxygenation as a bridge to durable mechanical circulatory support: an analysis of the STS-INTERMACS Database. Circulation. Heart failure, 13(3), e006387.

Retrospective INTERMACS registry study.

n=19,824

Follow-up: 2 years

In adult patients who received a durable MCS who were supported with and without VA ECMO, ECMO patients had inferior survival at 12 months (66%) than non-ECMO patients (75%; p<0.0001).

Registry studies with more relevant outcomes were included.

Mastoris I, Tonna JE, Hu J et al. (2022) Use of extracorporeal membrane oxygenation as bridge to replacement therapies in cardiogenic shock: insights from the Extracorporeal Life Support Organization. Circulation. Heart failure 15(1): e008777

Retrospective ELSO registry study

n=401

Follow-up: unclear

All-cause hospital mortality was 28.9% for people who received ECMO prior to Heart transplant or LVAD.

In those receiving LVAD mortality was 28.7% and heart transplant mortality was 29.1%.

Larger, more comprehensive registry studies were included.

Morrow DA and van Diepen S (2022) The extracorporeal membrane oxygenation in the therapy of cardiogenic shock (ECMO-CS) trial in perspective. European Heart Journal. Acute cardiovascular care 11(12): 933-935

Randomised controlled trial

n=117

Follow-up: 30 days

There was no significant difference between the two arms for all-cause death at 30 days.

Summary of ECMO-CS trial reported fully in Ostadal, 2023

Movahed MR, Soltani MA, Hashemzadeh M (2024) In patients with cardiogenic shock, extracorporeal membrane oxygenation is associated with very high all-cause inpatient mortality rate. Journal of Clinical Medicine 13(12): 3607

Retrospective study of US National Inpatient Sample database.

n=13,160

Total inpatient mortality 47.9% with ECMO. In a multivariate analysis adjusting for 47, ECMO utilisation remained highly associated with mortality (OR: 1.78, 95% CI: 1.6 to 1.9, p<0.001). Higher complications associated with the use of ECMO including bleeding, thromboembolic events, infections, and neurologic and vascular complications may contribute to higher mortality.

More comprehensive registry studies, which included CS aetiologies were included.

North M, Samara M, Eckman PM et al. (2022) Survivors of veno-arterial membrane oxygenation have good long-term quality of life. The International journal of artificial organs 45(10): 826-832

Single centre retrospective study, US

n=178 surveys (87% VA ECMO)

Follow-up: 9 months

Minnesota Living with Heart Failure Questionnaire (MLWHFQ) total scores improved over time (51.7 at 3 months, vs 37.7 at 6 months, vs 25.4 at greater than 9 months; p<0.01)

Larger registry studies with more relevant outcomes are included.

Nunez JI, Grandin EW, Reyes-Castro T et al. (2023) Outcomes with peripheral venoarterial extracorporeal membrane oxygenation for suspected acute myocarditis: 10-year experience from the Extracorporeal Life Support Organization Registry. Circulation: Heart Failure 16(7): e010152

Retrospective ELSO registry study

n=850

Follow-up: Hospital discharge

During the study period, in-hospital mortality was 58.3% for all all-comers receiving VA ECMO compared with 34.9% for patients with myocarditis (P<0.001).

1.8% and 2.4% of patients were bridged to heart transplant or LVAD respectively.

More comprehensive registry studies, which included more CS aetiologies were included.

Orbo MC, Karlsen SF, Pedersen EP et al. (2019) Health-related quality of life after extracorporeal membrane oxygenation: a single centre's experience. ESC heart failure 6(4): 701-710

Single centre retrospective study (Norway)

n=74 (87% VA ECMO)

Follow-up: Mean 6.5 years since ECMO

41% survival rate identified. 75% reported mental HRQoL (SF-36 Mental Component Summary, mean= 43, SD=5) or physical HRQL (SF-36 Physical Component Summary, mean=43, SD=4.5) within the normal range in comparison with age-matched population data from national norms. All but one responder lived independently without any organized care, and 90% reported no problems related to basic self-care. Half of those in working age had returned to work after ECMO treatment. Responders reported some degree of restrictions in usual daily activities (40%), problems with mobility (35%), anxiety/ depression (35%), or pain/ discomfort (55%). Improved HRQoL was significantly related to an extended time since ECMO treatment.

Larger registry studies with more relevant outcomes are included.

Ouweneel DM, Schotborgh JV, Limpens J et al. (2016) Extracorporeal life support during cardiac arrest and cardiogenic shock: a systematic review and meta-analysis. Intensive care medicine 42(12): 1922-1934

Systematic review and meta-analysis

n=3,333 (CA=3,098, CS after AMI=235),13 studies

Follow-up: 30 days

In cardiac arrest, the use of ECLS was associated with an increased survival rate as well as an increase in favourable neurological outcome. In the setting of cardiogenic shock there was an increased survival with ECLS compared with IABP.

More recent systematic reviews and meta-analyses included.

Paddock S, Meng J, Johnson N, Chattopadhyay R et al. (2024) The impact of extracorporeal membrane oxygenation on mortality in patients with cardiogenic shock post-acute myocardial infarction: a systematic review and meta-analysis. European Heart Journal Open; 4(1)

Systematic review and meta-analysis

n=1,622

11 studies

Follow-up: 30 days, 12 months

Meta-analysis demonstrates no significant difference in 30-day all-cause mortality with VA-ECMO compared with standard medical therapy (OR 0.91; 95% CI 0.65 to 1.27). Qualitative synthesis of the observational studies showed that age, serum creatinine, serum lactate, and successful revascularization are independent predictors of mortality.

Meta-analysis includes same RCTs as Elsaeidy et al. study included in key evidence but does not include safety data.

Sahli SD, Kaserer A, Braun J et al. (2022) Predictors associated with mortality of extracorporeal life support therapy for acute heart failure: single-center experience with 679 patients. Journal of Thoracic Disease 14(6): 1960-1971

Single centre retrospective study, Switzerland

n=679 (postcardiotomy n=215)

Follow-up: In-hospital

In-hospital mortality significantly varied between ECLS indications: 70.7% (152/215) for postcardiotomy, 67.9% (108/159) for cardiopulmonary resuscitation, 47.0% (110/234) for refractory cardiogenic shock, and 9.9% (7/71) for lung transplantation and expansive thoracic surgery (P<0.001).

Larger studies split by CS aetiology were included.

Schmidt M, Burrell A, Roberts L et al. (2015) Predicting survival after ECMO for refractory cardiogenic shock: the survival after veno-arterial-ECMO (SAVE)-score. European heart journal, 36(33), 2246–2256

Retrospective ELSO registry study

n=3,846

Follow-up: Hospital discharge

1,601 (42%) patients were alive at hospital discharge. Chronic renal failure, longer duration of ventilation prior to ECMO initiation, pre-ECMO organ failures, pre-ECMO cardiac arrest, congenital heart disease, lower pulse pressure, and lower serum bicarbonate were risk factors associated with mortality. 

More recent registry studies were included.

Truby L, Mundy L, Kalesan B et al. (2015) Contemporary outcomes of venoarterial extracorporeal membrane oxygenation for refractory cardiogenic shock at a large tertiary care center. ASAIO journal (American Society for Artificial Internal Organs: 1992) 61(4): 403-9

Single centre retrospective study, US.

n=179 (100 ECLS)

Follow-up: 30 days and hospital discharge

Overall, 38.6% of patients survived to discharge and 44.7% of patients survived to 30 days. Myocardial recovery was achieved in 79.7% of survivors and 39.1% were transitioned to a more durable device.

Larger more recent registry studies were included.

Wang AS, Nemeth S, Vinogradsky A et al. (2022) Disparities in the treatment of cardiogenic shock: does sex matter?. European journal of cardio-thoracic surgery: official journal of the European Association for Cardio-thoracic Surgery 62(6)

Retrospective ELSO registry study

n=9,888 (68% male)

Follow-up: Hospital discharge

After propensity score matching, there was no difference in in-hospital mortality. Female patients were more likely to experience limb ischaemia, whereas males were more likely to receive renal replacement therapy and have longer hospital stays. Multivariable logistic regression confirmed sex was not independently associated with mortality.

Registry studies with more relevant outcomes are included.

Weiner L, Mazzeffi MA, Hines EQ et al. (2020) Clinical utility of venoarterial-extracorporeal membrane oxygenation (VA ECMO) in patients with drug-induced cardiogenic shock: a retrospective study of the Extracorporeal Life Support Organizations' ECMO case registry. Clinical toxicology (Philadelphia, Pa.) 58(7): 705-710

Retrospective ELSO registry study

n=104

Follow-up: Hospital discharge

52.9% of the cases survived to discharge. VA ECMO significantly improved haemodynamics, acidaemia/ acidosis and ventilatory parameters. Non-survivors showed persistent acidaemia/ acidosis at 24 hours after VA ECMO cannulation compared to survivors. Renal replacement therapy (50.9%) and arrhythmia (26.3%) were the most frequently reported complications.

Larger, more comprehensive registry studies were included.

Wilson-Smith AR, Bogdanova Y, Roydhouse S et al. (2019) Outcomes of venoarterial extracorporeal membrane oxygenation for refractory cardiogenic shock: systematic review and meta-analysis. Annals of cardiothoracic surgery, 8(1), 1–8.

Systematic review and meta-analysis

n=17,515, 52 studies

Follow-up: 5 years

Aggregated survival rates at 1, 2, 3, 4 and 5 years were 36.7%, 34.8%, 33.8%, 31.7% and 29.9%, respectively.

Larger, more recent SLRs for multi-aetiology CS included with more comprehensive outcomes.

Zaki HA, Yigit Y, Elgassim M et al. (2024) A systematic review and meta-analysis unveiling the pivotal role of extracorporeal membrane oxygenation (ECMO) in drug overdose treatment optimization. Bulletin of emergency and trauma, 12(3), 103–110.

Systematic review and meta-analysis

n=694,10 studies

Follow-up: Hospital discharge

The pooled analysis of ECMO in drug-overdosed/ poisoned people showed survival to hospital discharge rate of 65.6% (95% CI: 51.5% to 77.4%, p=0.030). However, the

outcomes were highly heterogeneous (I²=83.47%), which could be attributed to the use of several medicines by different studies. ECMO was associated with a rate of adverse events of 23.1% (95% CI: 12.3% to 39.2%, p=0.002).

Larger, more comprehensive systematic literature reviews and meta-analysis included.

Zavalichi MA, Nistor I, Nedelcu A-E et al. (2020) Extracorporeal membrane oxygenation in cardiogenic shock due to acute myocardial infarction: a systematic review. BioMed Research International 2020: 6126534

Systematic review and meta-analysis

n=1,998,

9 studies

Follow-up: hospital discharge, 12 months

Survival rate varied from 30.0% to 79.2% at discharge and from 23.2% to 36.1% at 12 months. Reported serious adverse events were gastrointestinal bleeding (3.6%) and peripheral complications (8.5%).

No meta-analysis included.

Zhigalov K, Sa MPBO, Safonov D et al. (2020) Clinical outcomes of venoarterial extracorporeal life support in 462 patients: Single-center experience. Artificial organs 44(6): 620-627

Single centre retrospective study, Germany

n=462 (postcardiotomy n=357)

Follow-up: In-hospital

Overall, the in-hospital survival rate was 26%. There was no statistically significant difference between the groups: 26.3% for PCS and 24.8% for non-PCS, respectively (p>0.05). Weaning from VA-ECLS was possible in 44.3% for PCS and in 29.5% for non-PCS (p=0.004).

Larger studies split by CS aetiology were included.