SPC365

Venoarterial extracorporeal membrane oxigenation for infarct related cardiogenic shock: a real-world comparison of patient candidates, practices and outcomes

Session: Comunicações Orais - Sessão 14 - Choque cardiogénico e suporte circulatório mecânico
Speaker: Ana Rita Bello

Congress: CPC 2024
Topic: E. Coronary Artery Disease, Acute Coronary Syndromes, Acute Cardiac Care
Theme: 14. Acute Cardiac Care
Subtheme: 14.4 Acute Cardiac Care – Cardiogenic Shock
Session Type: Comunicações Orais
FP Number: ---
Authors: Ana Rita Bello; Rita Lima; Mariana Sousa Paiva; Joana Certo Pereira; Samuel Azevedo; Rita Sousa Barbosa; Débora Correia; João Presume; Catarina Brízido; Christopher Strong; Jorge Ferreira; António Tralhão

<p style="text-align:justify"><span style="font-size:12pt"><span style="font-family:Calibri,sans-serif"><strong><span style="font-size:11.0pt">[Introduction] </span></strong><span style="font-size:11.0pt">The recently published ECLS-SHOCK trial showed no benefit of venoarterial extracorporeal membrane oxygenation (VA-ECMO) for acute myocardial infarction related cardiogenic shock (AMI-CS). However, regional reproducibility patterns and each center&rsquo;s weighing of candidate selection variables are known to differ from clinical trials. Additionally, the prognostic impact of initiating VA-ECMO in a potentially significant proportion of trial-ineligible patients remains largely elusive.</span></span></span></p>

<p style="text-align:justify"><span style="font-size:12pt"><span style="font-family:Calibri,sans-serif"><strong><span style="font-size:11.0pt">[Aim]</span></strong><span style="font-size:11.0pt"> To assess the eligibility of a real-world cohort of AMI-CS patients based on the inclusion and exclusion criteria of ECLS-SHOCK and compare current VA-ECMO practices with a trial-based implantation strategy.</span></span></span></p>

<p style="text-align:justify"><span style="font-size:12pt"><span style="font-family:Calibri,sans-serif"><strong><span style="font-size:11.0pt">[Methods] </span></strong><span style="font-size:11.0pt">Retrospective single-center study&nbsp;of AMI-CS patients with ages between 18 and 80 years, admitted between&nbsp;January 2017 and&nbsp;October 2023. Baseline characteristics, patient severity and type of organ support were compared. We applied ECLS-SHOCK selection criteria and then assessed the primary outcome of 30-day mortality stratified in 4 groups by the presence of VA-ECMO: (1) eligible and cannulated, (2) eligible and not cannulated, (3) ineligible and cannulated and (4) ineligible and not cannulated. We further evaluated&nbsp;the persistence of hypotension/catecholamines and signs of hypoperfusion/hyperlactatemia at 24 and 48 hours post-AMICS-CS recognition.</span></span></span></p>

<p style="text-align:justify"><span style="font-size:12pt"><span style="font-family:Calibri,sans-serif"><strong><span style="font-size:11.0pt">[Results] </span></strong><span style="font-size:11.0pt">A total of 103 patients with AMI-CS were included (mean age 63&plusmn;15 years, 70% male), 44% (n=45) in SCAI D or E, mean serum lactate 4.9&plusmn;4.2 mmol/L and 28% (n=29) with out of hospital cardiac arrest. Applying the ECLS-SHOCK study&rsquo;s criteria,&nbsp;56% (n=58) of patients would have been eligible for VA-ECMO. The most frequent reason for exclusion in our practice was the presence of severe peripheral arterial disease (12%, n=11). In eligible patients, 19% (n=11) were cannulated, whereas in ineligible patients 20% (n=9) were cannulated. Only 55% of the cannulated patients fulfilled the study&rsquo;s criteria. 30-day mortality according to the defined groups was 55% (1), 43% (2), 44% (3) and 72% (4), p=0.006 (Figure 1). After adjusting for patient severity with the CardShock score, the presence of VA-ECMO was not associated with a lower mortality [HR 1.101 (CI95% 0.525-2.307), p=0.799]. In 16% (n=9) of all initially eligible patients who were not cannulated, hypotension/cathecolamines and hypoperfusion/hyperlactatemia did not persist at 48h from AMI-CS diagnosis - signaling shock resolution. None of these patients died.</span></span></span></p>

<p style="text-align:justify"><span style="font-size:12pt"><span style="font-family:Calibri,sans-serif"><strong><span style="font-size:11.0pt">[Conclusions] </span></strong><span style="font-size:11.0pt">In our real-world cohort, roughly half of all AMIC-CS patients would have been eligible for VA-ECMO. Our selection practices, however, markedly differed from the ECLS-SHOCK trial. 30-day mortality adjusted for clinical severity was similar between VA-ECMO support and usual treatment. Optimized selection strategies including better prediction of shock trajectories are warranted.</span></span></span></p>