OPTIMAL STRATEGY AND TIMING OF LEFT VENTRICULAR VENTING DURING VENO-ARTERIAL EXTRACORPOREAL LIFE SUPPOR FOR ADULTS IN CARDIOGENIC SHOCK A SYSTEMATIC REVIEW AND META-ANALYSIS
CCCF ePoster library. Randhawa V. 11/13/19; 283369; EP109
Varinder Randhawa
Varinder Randhawa
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Abstract
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ePoster
Topic: Systematic Review, Meta-Analysis, or Meta-Synthesis

Al-Fares, Abdulrahman1,2,5, Randhawa, Varinder6, Englesakis, Marina3, McDonald, Michael4, Nagpal, Dave8, Estep, Jerry6,  Soltesz, Ed7, and Fan, Eddy1,2
 
1Interdepartmental Division of Critical Care Medicine, 2Extracorporeal Life Support Program, 3Health Sciences Library, and 4Division of Cardiology, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada; 5Al-Amiri Hospital, Ministry of Health, Kuwait; Departments of 6Cardiovascular Medicine and 7Thoracic and Cardiovascular Surgery, Kaufman Center for Heart Failure, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio, United States; and 8Divisions of Cardiac Surgery and Critical Care, London Health Sciences Center, London, Ontario, Canada.
 


INTRODUCTION AND OBJECTIVE
Veno-arterial extracorporeal life support (VA-ECLS) is widely used to treat refractory cardiogenic shock. However, increased left ventricular (LV) afterload in VA-ECLS can lead to LV distension and stasis, which in turn may exacerbate myocardial ischemia, arrhythmias, pulmonary edema, thrombo-embolic phenomenon and timely myocardial recovery. The purpose of this meta-analysis was to explore the efficacy, safety, and optimal timing of adjunctive LV unloading strategies.
 
METHODS
A systematic search was performed of Medline, EMBASE, PubMed, CDSR, CCRCT, CINAHL, ClinicalTrials.Gov, and WHO ICTRP from inception until January 2019 for all relevant studies including LV venting in accordance PRISMA protocols. Data were analysed for mortality and wean from VA-ECLS on the basis of timing of LV venting (< 12hrs or >12hrs). All eligible studies were assessed for methodological quality using the ROBINS-I tool. Statistical heterogeneity for the outcomes among studies was assessed using the I2-test and reporting biases using funnel plots of the treatment effect against study precision. Inverse variance, random effects model was used to account for between-study heterogeneity and assess the overall risk ratio. Pooled data were summarized using either means or medians (and interquartile range) for continuous parametric and non-parametric variables, respectively and categorical variables were reported as counts and percentages. P values < 0.05 by chi-squared test for difference in proportions or two-sided t-test for continuous variables, were considered statistically significant.
 
RESULTS
A total of 7,995 patients were included from 62 observational studies, wherein 3,458 patients had LV venting during VA-ECLS. LV venting significantly improved wean from VA-ECLS (OR 0.62; 95% CI 0.47-0.83; p=0.001) and reduced short-term 30-day (RR 0.86; 95% CI 0.77-0.96; p=0.008) but not in-hospital (RR 0.92; 95% CI 0.83-1.01; p=0.09) or long-term up to 6 months (RR 0.96; 95% CI 0.90-1.03; p=0.27) mortality (Figure 1). Early (<12h, RR 0.86; 95% CI 0.75-0.99; p=0.03) but not late (>12h, RR 0.99; 95% CI 0.71-1.38; p=0.93) LV venting significantly reduced short-term mortality. Moreover, a significant improvement in wean from VA-ECLS overall (OR 0.62; 95% CI 0.47-0.83; p=0.001) and with early (OR 0.68; 95% CI 0.50-0.91; p=0.005), but not late (OR 1.21; 95% CI 0.19-7.57; p=0.84) LV venting. Patients with LV venting spent more time on VA-ECLS (3.6 vs. 2.8 days, p<0.001), and mechanical ventilation (7.1 vs. 4.6 days, p=0.013) (Table 1).
 
CONCLUSIONS
LV venting, especially if done early (<12h), appears to improve wean from ECLS and reduce short-term but not in-hospital or long-term mortality. Future studies are required to explore the full impact of any or early LV adjuncts on mortality and morbidity outcomes.
 


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