Extracorporeal membrane oxygenation not superior to conservative therapy in cardiogenic shock

In patients with rapidly deteriorating or severe cardiogenic shock, the immediate implementation of extracorporeal membrane oxygenation (ECMO) did not outperform an early conservative strategy, consisting of inotropes and vasopressors, and secondary ECMO in case of haemodynamic worsening.

“According to the 2021 guidelines of the European Society of Cardiology (ESC) for the management of heart failure, patients with cardiogenic shock should receive oxygen for early haemodynamic stabilisation (class I recommendation),” explained Prof. Petr Ostadal (Charles University, Czech Republic) [1]. “Furthermore, inotropes/vasopressors (class 2b) may be considered and ventilatory support (class 2a) and short-term mechanical circulatory support (MCS) should be considered (class 2a) in this population.”

The multicentre, randomised, investigator-initiated, academic ECMO-CS trial (NCT02301819) compared an early conservative therapy with inotropes and vasopressors (n=59) to immediate ECMO implementation (n=58) in participants with severe or rapidly deteriorating cardiogenic shock [2]. Importantly, secondary ECMO was allowed in case of haemodynamic worsening in the conservative arm, defined as a rise of lactate by 3 mmol/L. The primary endpoint was a composite of all-cause mortality, resuscitated circulatory arrest, and implementation of another mechanical circulatory support device at 30 days.

ECMO did not significantly alter the rate of the primary outcome compared with the conservative therapy in the study population (HR 0.72; 95% CI 0.46–1.12; P=0.21). The use of another mechanical circulatory support was more frequently observed in the conservative arm than in the ECMO arm (42.4% vs 17.2%; HR 0.38; 95% CI 0.18–0.79) and 23 participants in the conservative arm required secondary ECMO support (39.0%). The safety analysis did not reveal differences in the incidence of serious adverse events such as bleeding, leg ischaemia, stroke, pneumonia, or sepsis, between the 2 study arms. Furthermore, the type of shock, rapidly deteriorating or severe, did not appear to have a distinctive influence on the primary outcome.

Overall, the trial did not demonstrate the superiority of ECMO within the sample size studied. Prof. Ostadal concluded that the early haemodynamic stabilisation using inotropes and vasopressors, with secondary use of ECMO in case of haemodynamic worsening, is comparable to the immediate implementation of ECMO in participants with acute cardiogenic shock.

1. 
   
   1. McDonagh TA, et al. Eur Heart J. 2021;42(36):3599–3726.
   2. Ostadal P, et al. Extracorporeal membrane oxygenation in the therapy of cardiogenic shock: primary results from the multicenter, randomized ECMO-CS Trial. LBS.03, AHA Scientific Sessions 2022, 05–07 November, Chicago, USA.

 

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Posted on 11 January 2023