High mortality from heart failure despite mechanical cardiovascular support

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High mortality from heart failure despite mechanical cardiovascular support

Worldwide, there is a proliferation in the use of mechanical active cardiovascular support. The hope is to use these assist devices to improve survival after the most severe form of acute heart failure, cardiogenic shock. A recent clinical study, led by heart specialist Prof. Holger Thiele, has shown that these devices do not reduce mortality after cardiogenic shock within 30 days. The result will almost certainly influence treatment guidelines in the future. The study was recently presented at the annual meeting of the European Society of Cardiology and published simultaneously with an additional meta-analysis in the two most renowned medical journals, The Lancet and the New England Journal of Medicine.

Cardiogenic shock is triggered by a pumping failure of the heart and often by a heart attack. The heart then no longer manages to maintain circulation. After an acute heart attack with cardiogenic shock, those affected have a risk of dying within 30 days of almost 50 percent. For more than ten years, patients have often been treated with what is known as venoarterial extracorporeal membrane oxygenation, or VA-ECMO or ECLS. This mechanical circulatory support refers to the use of systems that help the diseased heart pump blood around the body. VA-ECMO can theoretically take over the function of the heart as well as the lungs for a certain time. However, this form of therapy also leads to possible complications, such as bleeding or leg ischemia, a sudden interruption of the blood supply in the leg, due to the large cannulas used.

Heart specialist Prof. Holger Thiele, Director of the University Clinic for Cardiology at the Heart Center Leipzig, HELIOS Endowed Professor at the University of Leipzig and President of the German Society of Cardiology, has now conducted a large clinical study in which a total of 420 patients at 44 centers in Germany and Slovenia participated. In patients with acute myocardial infarction and subsequent cardiogenic shock, VA-ECMO therapy plus drug therapy in the intensive care unit was compared with drug therapy in the intensive care unit alone.

-Contrary to our study hypothesis, VA-ECMO does not reduce 30-day mortality. In contrast to standard therapy, mortality was not statistically significantly different at 47.8 percent versus 49 percent. The VA-ECMO group actually had more complications such as major bleeding or leg ischemia. So we need to rethink and reduce the bleeding induced by the mechanical systems as well as the additional inflammatory stimulus. Probably less is more in cardiogenic shock-, Thiele explains the main results of the study. The results could additionally be confirmed with a patient-based meta-analysis that compared the results of all four previous studies of mechanical cardiovascular support with VA-ECMO versus control therapy. Again, VA-ECMO did not show a survival benefit with more complications.

-The study results show that we need to reduce the frequency of VA-ECMO therapy in Germany and internationally. The future guidelines will certainly take this up soon and downgrade the recommendation for therapy with active mechanical cardiovascular support systems or even generally no longer recommend it in routine practice," says Thiele. The heart specialist is planning many more follow-up studies, including a one-year follow-up to identify any differences over time. -Our goal continues to be to reduce the very high mortality in cardiogenic shock. We can only show this through innovative studies," says Prof. Thiele.

Holger Thiele has been Director of the University Clinic for Cardiology - HELIOS Endowed Professorship at Herzzentrum Leipzig since 2017. In addition to his clinical activities at Herzzentrum Leipzig, Professor Thiele and his team are intensively involved in research and teaching at the Medical Faculty of the University of Leipzig as part of the HELIOS Endowed Professorship.

Original publications:

The New England Journal of Medicine: Extracorporeal Life Support in Infarct-Related Cardiogenic Shock. DOI: 10.1056/NEJMoa2307227

The Lancet: Venoarterial extracorporeal membrane oxygenation in patients with infarct-related cardiogenic shock: An individual patient data meta-analysis of randomised trials. DOI: https://doi.org/10.1016/S­0140-6736(­23)01607-0

Anne Grimm