Clinical paperIntra-aortic balloon pump use in out-of-hospital cardiac arrest patients who underwent extracorporeal cardiopulmonary resuscitation
Introduction
Out-of-hospital cardiac arrest (OHCA) is a global health problem. The incidence of OHCA treated by emergency medical services in people of any age is 74.3 individuals per 100,000 individuals, according to the 2018 Cardiac Arrest Registry to Enhance Survival.1 The American Heart Association reported that the survival rate of patients with OHCA after hospital discharge is approximately 10%, which remains low despite advances in cardiopulmonary resuscitation (CPR) and post-cardiac arrest care.1
Extracorporeal membrane oxygenation (ECMO)-assisted cardiopulmonary resuscitation (ECPR) is the application of venoarterial ECMO (VA-ECMO) in patients with cardiac arrest who are refractory to conventional CPR.2 ECPR is reportedly associated with better clinical outcomes of patients with OHCA.3, 4, 5 Mortality after OHCA is mainly attributed to cerebral and cardiac dysfunction accompanied by prolonged whole-body ischaemia.6 The main objective of ECPR is to restore haemodynamics and gas exchange. VA-ECMO provides time for cardiopulmonary interventions, including percutaneous coronary interventions, necessary to obtain adequate spontaneous circulation.
However, left ventricular (LV) dilation in VA-ECMO could occur owing to retrograde blood flow from the ECMO circuit, which increases the afterload. First, impaired cardiac function, including post-cardiac arrest, might prevent sufficient ejection, resulting in increased LV end-diastolic pressure and left atrial pressure, leading to pulmonary oedema and subsequent hypoxia. Second, LV dilation also increases wall stress and myocardial oxygen consumption, both of which further impair cardiac recovery and negatively affect prognosis.7, 8
A concomitant intra-aortic balloon pump (IABP) adjunct to VA-ECMO is widely applied in clinical practice to reduce the burden on the heart caused by VA-ECMO. In addition to the known afterload reduction and increased coronary perfusion, pulsation recovery, and indirect LV unloading have been discussed as major advantages of performing simultaneous VA-ECMO and IABP.9, 10 However, conflicting results are available for simultaneous VA-ECMO and IABP.11, 12, 13, 14, 15 Several studies have previously reported that the concomitant use of IABP with VA-ECMO is effective in patients with cardiogenic shock.12, 16, 17 Conversely, some studies have reported that the same technique is ineffective in patients with cardiogenic shock.11, 18, 19 Few studies have also reported the benefits of adding IABP to VA-ECMO in post-cardiac arrest care.20 However, to our knowledge, no study has investigated the effectiveness of IABP use in patients with OHCA who underwent ECPR.
This study aimed to investigate the effect of IABP use on short-term clinical outcomes in adult patients who underwent ECPR using a nationwide multicentre registry in Japan.
Section snippets
Study design and setting
This study was a retrospective analysis of data collected between June 2014 and December 2019 from the Japanese Association for Acute Medicine OHCA (JAAM-OHCA) registry. This registry provides a nationwide, multicentre, prospectively focused collection of pre-hospital and in-hospital data from patients with OHCA in Japan. The registry included all patients with OHCA transported to participating institutions. As previously reported, pre-hospital data were obtained from the All-Japan Utstein
Patient enrolment
During the study period, 51,199 adult patients with OHCA were enrolled in the JAAM-OHCA registry. Among them, 2135 patients who underwent ECPR were eligible for this study (Fig. 1). No patient had missing data for IABP use and CPC at 30 days after cardiac arrest.
Patient characteristics and outcomes
The demographic, pre-hospital, and in-hospital characteristics of the patients are presented in Table 1. IABPs were used in 1173 patients but not in the remaining 962 patients (Fig. 1). Missing data are described in Table S1 (Appendix 2
Main findings
We investigated the relationship between IABP use and short-term clinical outcomes in adult patients who underwent ECPR. Regarding 30-day survival, IABP use had an advantage according to the PSM analysis. However, there was no significant association between IABP use and 30-day neurologically favourable outcome in survived patients 30 days after cardiac arrests.
Effect of adjunctive intra-aortic balloon pump use in venoarterial-extracorporeal membrane oxygenation support
The implementation of adjunctive IABP in VA-ECMO remains controversial. Based on an experimental study, IABP improved the oxygen
Conclusions
Using PSM comparisons, we investigated the association between IABP use and short-term clinical outcomes in adult patients who underwent ECPR. IABP use in patients with OHCA who underwent ECPR was associated with higher 30-day survival rates. However, among survived patients, there was no significant association between IABP use and 30-day neurological outcome. A further well-designed prospective study is needed to address the knowledge gap identified in this retrospective data analysis.
Funding
The JAAM-OHCA registry was supported by scientific research grants from the Ministry of Education, Culture, Sports, Science and Technology of Japan (16K09034 and 15H05006) and the Ministry of Health, Labor, and Welfare of Japan (Grant No. 25112601). The founders of this study had no role in study design, data analysis, data interpretation, or writing of this manuscript.
Conflicts of interest
None.
CRediT authorship contribution statement
Masahiro Kashiura: Conceptualization, Methodology, Formal analysis, Data curation, Writing – original draft, Visualization. Yuki Kishihara: Methodology, Writing – review & editing, Supervision. Hidechika Ozawa: Methodology, Writing – review & editing, Supervision. Shunsuke Amagasa: Conceptualization, Methodology, Writing – review & editing, Supervision. Hideto Yasuda: Software, Conceptualization, Methodology, Writing – review & editing, Supervision. Takashi Moriya: Writing – review & editing,
Acknowledgements
We would like to thank Editage (www.editage.com) for providing writing support.
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