Early extracorporeal life support (ECLS) doesn’t improve survival in patients with acute myocardial infarction complicated by cardiogenic shock who’re scheduled for early revascularization, based on late breaking research presented in a Hot Line session today at ESC Congress 2023.
Cardiogenic shock is the leading reason behind death in hospitalized patients with acute myocardial infarction. Evidence-based treatment is proscribed to immediate revascularisation of the offender lesion. Nonetheless, mortality stays high, reaching 40-50% inside 30 days. Ongoing efforts to enhance outcomes have led to a rise in using energetic mechanical circulatory support devices to realize hemodynamic stabilization in severe shock. Specifically, using venoarterial extracorporeal membrane oxygenation (VA-ECMO), also called ECLS, has risen by greater than 10 times lately.
ECLS enables full circulatory and respiratory support, which differentiates it from other devices. Nonetheless, evidence for ECLS in patients with cardiogenic shock and acute myocardial infarction is restricted to observational studies and three small randomized trials.7-10 The potential advantages of hemodynamic support could be outweighed by a substantial risk of device-associated local and systemic complications including bleeding, stroke, limb ischemia and hemolysis.
ECLS-SHOCK was the primary randomized trial to research the effect of ECLS on mortality in patients with acute myocardial infarction complicated by cardiogenic shock. A complete of 420 patients with acute myocardial infarction and cardiogenic shock scheduled for early revascularisation were enrolled from 44 centers in Germany and Slovenia. The median age of participants was 63 years and 19% were women. Patients were randomly assigned to early ECLS plus usual medical treatment (ECLS group) or to usual medical treatment alone (control group).
The first endpoint was all-cause death at 30 days. Secondary endpoints included length of mechanical ventilation, time to hemodynamic stabilization and want for renal substitute therapy. Safety endpoints included moderate or severe bleeding and peripheral vascular complications requiring intervention
A complete of 417 patients were included in the ultimate analyses. The first endpoint of all-cause death at 30 days occurred in 100 of 209 patients (47.8%) within the ECLS group and in 102 of 208 patients (49.0%) within the control group (relative risk [RR], 0.98; 95% confidence interval [CI] 0.80 to 1.19; p=0.81).
The median duration of mechanical ventilation was longer within the ECLS group: 7 days (interquartile range [IQR] 4-12) within the ECLS group versus 5 days (IQR 3-9) within the control group, Hodges-Lehmann estimate of the difference between groups, 1 (95% CI 0 to 2). The time to hemodynamic stabilization and rates of renal substitute therapy were similar between treatment groups.
Regarding safety endpoints, moderate or severe bleeding occurred more often within the ECLS group: 23.4% of patients within the ECLS group versus 9.6% of patients within the control group (RR 2.44; 95% CI 1.50 to three.95). Peripheral vascular complications requiring intervention occurred also more often within the ECLS group: 11.0% of patients within the ECLS group versus 3.8% of patients within the control group (RR 2.86; 95% CI 1.31 to six.25).
The outcomes of ECLS-SHOCK demonstrated no reduction in 30-day mortality with early ECLS therapy and a rise in complications. The findings may result in the discontinued routine use of those devices in clinical practice.”
Holger Thiele, Principal Investigator, Professor, Leipzig Heart Centre at Leipzig University, Germany
Source:
European Society of Cardiology