ECMO has no effect on survival benefit in shock patients

There is substantial interest in use of mechanical circulatory support (MCS) in a variety of disease states, including cardiogenic shock, cardiac arrest, and profound hypoxemia. Evidence for MCS efficacy and its hazards has been mixed across multiple indications.

The ECLS-SHOCK investigators performed a randomized trial of VA-ECMO at the time of coronary angiography among adult patients (≤80 years of age) with cardiogenic shock at the time of diagnostic angiography with intent to revascularize (similar to the patient presented in this question). The trial was powered to detect a 14% absolute risk reduction for mortality. In the ECLS-SHOCK trial, 420 (417 in the analysis cohort) patients in Germany or Slovenia were randomly assigned to revascularization plus VA-ECMO vs usual care with revascularization. Notably, 78% of patients had experienced cardiac arrest with cardiopulmonary resuscitation before random assignment, and the revascularization procedure was percutaneous coronary intervention (PCI) in 97% of patients. The primary outcome of mortality was not different between the two groups (48% vs 49%). In addition to a lack of efficacy, moderate or severe bleeding (23% vs 10%) and vascular complications treated with surgery or interventional therapy (11% vs 4%) were more common in the ECLS group. In terms of success of PCI, there was no important difference between the two groups.

On the basis of these findings from the ECLS-SHOCK trial (plus consistent results from the similar but underpowered ECMO-CS trial for patients with cardiogenic shock).123

Footnotes

  1. SEEK Questionnaires ↩

  2. Ostadal P, Rokyta R, Karasek J, et al; ECMO-CS Investigators. Extracorporeal membrane oxygenation in the therapy of cardiogenic shock: results of the ECMO-CS randomized clinical trial. Circulation. 2023;147(6):454-464. PubMed ↩

  3. Thiele H, Zeymer U, Akin I, et al; ECLS-SHOCK Investigators. Extracorporeal life support in infarct-related cardiogenic shock. N Engl J Med. 2023;389(14):1286-1297. PubMed ↩