Fulbright Fellow/ Interventional Cardiologist, United States
Disclosure(s):
Christian Said, MBBS MSc: No financial relationships to disclose
Background: Venoarterial extracorporeal membrane oxygenation (ECMO) is increasingly used for cardiogenic shock, often combined with intra-aortic balloon pumps (IABP) or microaxial flow devices. Understanding temporal trends in these combination strategies is essential for optimizing shock management protocols and institutional resource allocation.
Methods: We analyzed 11,386 cardiogenic shock patients from an international multicentre registry (2021-2025), identifying 1,509 patients receiving ECMO-based mechanical circulatory support strategies. Patients were categorized as: ECMO alone (n=745, 49%), ECMO with microaxial flow device (n=532, 35%; 323 percutaneous, 209 surgical), or ECMO with IABP (n=232, 15%). We examined baseline characteristics, shock severity markers, device timing patterns, and temporal trends in utilization.
Outcome: Combination VA-ECMO strategies were employed in 764 patients (51%), remaining stable across years (p=0.49). Between 2022-2025, microaxial flow device use increased (28% to 42%, p=0.002) driven by both percutaneous (61%) and surgical devices and whilst IABP use declined (20% to 9%, p=0.001). Escalation strategies (VA-ECMO first, then second device added) predominated (66%), remaining stable from 2021-2025 (p=0.87).
Baseline characteristics differed significantly across strategies. VA-ECMO with microaxial flow device had higher SCAI stage D/E (54% vs 48% p=0.03), lower median systolic blood pressure (105 vs 111 mmHg, p< 0.001), higher acute coronary syndrome rates (39% vs 22%, p< 0.001), and fewer females (21% vs 34%, p< 0.001) compared to VA-ECMO alone. In contrast, VA-ECMO-IABP patients demonstrated lower shock severity with fewer out-of-hospital cardiac arrests (10% vs 20%, p=0.001), lower SCAI D/E rates (30% vs 48%, p< 0.001), and lower median lactate (2.8 vs 3.5 mmol/L, p=0.008) compared to VA-ECMO alone. Time to second device was shorter when added after VA-ECMO versus VA-ECMO added after initial device (microaxial: 3.6 vs 10.8 hours, p< 0.001; IABP: 1.9 vs 16.8 hours, p< 0.001). Overall mortality was 48%, with similar native heart survival across strategies (VA-ECMO alone 51%, with microaxial 51%, with IABP 56%, p=0.36).
Conclusion: Combination VA-ECMO strategies remained most common, with significant shifts toward microaxial devices and away from IABP. Microaxial patients demonstrated higher shock severity than VA-ECMO alone. These evolving patterns inform institutional resource planning and highlight the need for novel approaches to improve outcomes in multi-device mechanical circulatory support.
