Mechanical Circulatory Support Devices
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The need for a refined, phenotype-driven approach to patient selection for LV unloading in ECMO-supported cardiogenic shock is highlighted, as LV unloading during VA-ECMO was not associated with improved survival at 60 days.
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BACKGROUND: Conflicting data exist regarding the survival benefit of mechanical left ventricular (LV) unloading in patients receiving peripheral venoarterial extracorporeal membrane oxygenation (VA-ECMO) for refractory cardiogenic shock (CS). In this study, we aimed to assess the effect of LV unloading (Impella or intra-aortic balloon pump [IABP]) on 60-day mortality in patients with refractory CS treated with VA-ECMO. METHODS: We conducted a retrospective bi-center study including consecutive patients requiring VA-ECMO for ≥ 48 h in two high-volume ECMO centers between 2019 and 2023, using the target trial emulation framework. Patients were classified as receiving VA-ECMO alone or VA-ECMO with LV unloading if the unloading strategy was applied within 24 h after ECMO implantation. Propensity-score overlap weighting was applied to adjust for baseline differences. The primary endpoint was 60-day mortality. Secondary outcomes included ECMO weaning rates and device-related complications. RESULTS: Among 264 patients (76% male, mean age 53 ± 14 years), 138 (52.2%) received VA-ECMO alone and 126 (47.8%) underwent LV unloading (78 IABP, 48 Impella), 2 were lost to follow-up. Unloading was not associated with improved 60-day mortality (weighted risk difference: 1.4% [95% CI: -11.8%, 14.6%], p = 0.84). No significant differences were observed in ECMO weaning rates, but device-related complications were more frequent in the unloading group. CONCLUSION: In this propensity-score weighted analysis, LV unloading during VA-ECMO was not associated with improved survival at 60 days. These hypothesis-generating findings highlight the need for a refined, phenotype-driven approach to patient selection for LV unloading in ECMO-supported cardiogenic shock.
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@article{Dettling2026Left,
title = {Left ventricular unloading during VA-ECMO for refractory cardiogenic shock: a target trial emulation multicenter analysis},
author = {Angela Dettling and Ouriel Saura and Lisa Dilange and David Levy and Manuela Lucenteforte and Benedikt N. Beer and Charles Juvin and Jonas Sundermeyer and Guillaume Hekimian and Marvin Kriz and Alexander Bernhardt and Stefan Kluge and Matthieu Schmidt and Pascal Leprince and Guillaume Lebreton and David Hajage and Benedikt Schrage and Alain Combes},
journal = {Critical Care},
year = {2026},
doi = {10.1186/s13054-026-06213-4},
url = {https://doi.org/10.1186/s13054-026-06213-4}
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