Feasibility of veno-arterial extracorporeal life support in awake patients with cardiogenic shock

TL;DR

This study shows that VA-ECLS can be safely used in awake patients with cardiogenic shock, with outcomes similar to those who are intubated.

Contribution

The study demonstrates the feasibility and safety of VA-ECLS in non-intubated patients with cardiogenic shock.

Findings

Awake patients had 100% technical success with percutaneous femoral cannulation without intubation.

In-hospital mortality and adverse event rates were similar between awake and intubated patients.

Awake patients had better long-term outcomes, such as higher rates of heart transplantation and ventricular assist device use.

Abstract

This study sought to demonstrate outcomes of veno-arterial extracorporeal life support (VA-ECLS) in non-intubated (‘awake’) patients with cardiogenic shock, as very few studies have investigated safety and feasibility in this population.

This was a retrospective review of 394 consecutive VA-ECLS patients at our institution from 2017 to 2021. We excluded patients cannulated for indications definitively associated with intubation. Patients were stratified by intubation status at time of cannulation and baseline differences were balanced by inverse probability of treatment weighting. The primary outcome was in-hospital mortality while secondary outcomes included adverse events during ECLS and destination at discharge.

Out of 135 patients in the final cohort, 79 were intubated and 56 were awake at time of cannulation. All awake patients underwent percutaneous femoral cannulation with technical success of 100% without intubation. Indications for VA-ECLS in awake patients included acute decompensated heart failure (64.3%), pulmonary hypertension or massive pulmonary embolism (12.5%), myocarditis (8.9%) and acute myocardial infarction (5.4%). After adjustment, awake and intubated patients had similar ECLS duration (7 vs 6 days, P = 0.19), in-hospital mortality (39.6% vs 51.7%, P = 0.28), and rates of various adverse events. Intubation status was not a significant risk factor for 90-day mortality (hazard ratio [95% confidence interval]: 1.26 [0.64, 2.45], P = 0.51) in multivariable analysis. Heart transplantation (15.1% vs 4.9%) and ventricular assist device (17.4% vs 2.2%) were more common destinations at discharge in awake patients than intubated patients (P = 0.02).

Awake VA-ECLS is safe and feasible with comparable outcomes as intubated counterparts in select cardiogenic shock patients.

Veno-arterial extracorporeal life support (VA-ECLS) has increasingly become an important tool in the treatment of patients with refractory cardiogenic shock (RCS) [1].

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