{"id":24644,"date":"2023-09-06T04:55:00","date_gmt":"2023-09-05T20:55:00","guid":{"rendered":"http:\/\/csccm.org.cn\/?p=24644"},"modified":"2023-09-06T05:44:53","modified_gmt":"2023-09-05T21:44:53","slug":"nejm%e5%8f%91%e8%a1%a8%e8%bf%b0%e8%af%84%ef%bc%9a%e5%b8%b8%e8%a7%84%e6%97%a9%e6%9c%9f%e4%bd%bf%e7%94%a8%e4%bd%93%e5%a4%96%e7%94%9f%e5%91%bd%e6%94%af%e6%8c%81%e6%b2%bb%e7%96%97%e5%bf%83%e6%a2%97","status":"publish","type":"post","link":"https:\/\/csccm.org.cn\/?p=24644","title":{"rendered":"[NEJM\u53d1\u8868\u8ff0\u8bc4]\uff1a\u5e38\u89c4\u65e9\u671f\u4f7f\u7528\u4f53\u5916\u751f\u547d\u652f\u6301\u6cbb\u7597\u5fc3\u6897\u76f8\u5173\u5fc3\u6e90\u6027\u4f11\u514b\uff1f"},"content":{"rendered":"\n

EDITORIAL<\/a><\/p>\n\n\n\n

Routine Early ECLS in Infarct-Related Cardiogenic Shock?<\/h1>\n\n\n\n

Jane A. Leopold, Darren B. Taichman<\/h3>\n\n\n\n

N Engl J Med August 26, 2023
DOI: 10.1056\/NEJMe2309395<\/h3>\n\n\n\n

The 30-day mortality among patients with an acute myocardial infarction complicated by cardiogenic shock who undergo coronary-artery revascularization procedures approaches 50% in contemporary clinical trials and registries.1<\/a><\/sup> In patients with persistent hemodynamic compromise and organ hypoperfusion despite resuscitative measures, mechanical circulatory support may improve both systemic and myocardial perfusion, reduce ventricular workload, and provide periprocedural support for percutaneous coronary intervention (PCI).2<\/a><\/sup><\/p>\n\n\n\n

Among the available percutaneous devices, extracorporeal life support (ECLS) with venoarterial extracorporeal membrane oxygenation provides complete cardiopulmonary circulatory support and manages refractory respiratory failure. Despite its increasing use in patients with myocardial infarction and cardiogenic shock, data regarding the effect of ECLS on mortality are limited. In a small, randomized trial involving patients with cardiogenic shock attributable to either myocardial infarction and associated complications or decompensated heart failure, investigators compared early ECLS with standard care plus ECLS added only as needed. There was no between-group difference in the primary composite outcome consisting of death from any cause, the need for another mechanical circulatory support device, or resuscitated cardiac arrest at 30 days.3<\/a><\/sup> However, the small size of the trial (122 patients at four centers) leaves unclear whether routine early ECLS may provide a mortality benefit for patients with myocardial infarction and cardiogenic shock.<\/p>\n\n\n\n

Thiele and colleagues now present in the Journal<\/em> the results of the ECLS-SHOCK trial, in which investigators tested whether routine early implementation of ECLS improved survival in patients with myocardial infarction and cardiogenic shock who were undergoing revascularization.4<\/a><\/sup> Unfortunately, the researchers found that this use of ECLS did not result in the desired outcome. A total of 417 patients from 44 centers were randomly assigned to receive ECLS plus medical treatment immediately after coronary angiography or to receive medical treatment alone (control group). Two thirds of the patients had an ST-segment elevation myocardial infarction (STEMI), and more than half had multivessel coronary artery disease. Death from any cause at 30 days (the primary end point) occurred in 47.8% of the patients in the ECLS group and in 49.0% of those in the control group (relative risk, 0.98; 95% confidence interval, 0.80 to 1.19; P=0.81). Although the duration of mechanical ventilation and stay in the intensive care unit were longer in the ECLS group, there were no apparent between-group differences in the frequency of renal replacement therapy, repeat revascularization, myocardial reinfarction, rehospitalization for congestive heart failure, or poor neurologic outcome (a post hoc outcome). However, moderate or severe bleeding and peripheral ischemic complications were more frequent in the ECLS group. Escalation to an intraaortic balloon pump or a percutaneous ventricular assist device occurred in 28 patients in the control group, and crossover to ECLS occurred in 26 patients. Although substantial crossover might have biased the results toward the null, the findings of a prespecified as-treated analysis were consistent with the primary results.<\/p>\n\n\n\n

The patients who were enrolled in the ECLS-SHOCK trial were at high risk for adverse outcomes and were considered to be the most likely to benefit from mechanical circulatory support: 77.7% received cardiopulmonary resuscitation before randomization; the median blood pH was 7.2, the median lactate level was 6.9 mmol per liter, and the median left ventricular ejection fraction was 30%. According to the Society for Cardiovascular Angiography and Interventions shock stages,5<\/a><\/sup> the condition of 48.4% of all patients in the trial was categorized as either deteriorating (stage D) or in extremis (stage E), and ECLS was initiated before or during the revascularization procedure in 47.7%. Nonetheless, the lack of apparent mortality benefit appeared to be consistent across multiple subgroup analyses, including those performed according to sex, age, the presence or absence of diabetes, STEMI or non-STEMI, anterior myocardial infarction, a lactate level of more than 6 mmol per liter, or receipt of cardiopulmonary resuscitation. Notably, a subgroup analysis according to shock-severity stage was not included. The lack of a mortality benefit with ECLS in this trial corresponds to the findings of other randomized trials of mechanical circulatory support devices in patients with myocardial infarction and cardiogenic shock.1,2<\/a><\/sup><\/p>\n\n\n\n

Whether to implement ECLS requires consideration of its potential complications that may influence a patient\u2019s risk of death, including increased left ventricular afterload, leg ischemia, acute kidney injury, stroke, and clinically significant bleeding.6,7<\/a><\/sup> However, on the basis of the reported event rates, it is not clear whether any of these factors explains the lack of mortality benefit associated with early ECLS implementation in this trial.<\/p>\n\n\n\n

Will the results of the ECLS-SHOCK trial change current clinical practice? If the goal of ECLS is to improve 30-day mortality, these data should steer interventional and critical care cardiologists away from its early routine implementation for all or even most patients with myocardial infarction and cardiogenic shock. There will be some patients in this population for whom ECLS is necessary and lifesaving, but the results of the ECLS-SHOCK trial do not tell us which ones. For now, the best course may be to reserve the early initiation of ECLS for those patients with infarct-related cardiogenic shock in whom the likely benefits more clearly outweigh the potential harms. We need further studies to tell us who they are.<\/p>\n","protected":false},"excerpt":{"rendered":"

EDITORIAL Routine Early ECLS in Infarct-Related Cardiog […]<\/p>\n","protected":false},"author":3,"featured_media":0,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":[],"categories":[24,23],"tags":[],"_links":{"self":[{"href":"https:\/\/csccm.org.cn\/index.php?rest_route=\/wp\/v2\/posts\/24644"}],"collection":[{"href":"https:\/\/csccm.org.cn\/index.php?rest_route=\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/csccm.org.cn\/index.php?rest_route=\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/csccm.org.cn\/index.php?rest_route=\/wp\/v2\/users\/3"}],"replies":[{"embeddable":true,"href":"https:\/\/csccm.org.cn\/index.php?rest_route=%2Fwp%2Fv2%2Fcomments&post=24644"}],"version-history":[{"count":1,"href":"https:\/\/csccm.org.cn\/index.php?rest_route=\/wp\/v2\/posts\/24644\/revisions"}],"predecessor-version":[{"id":24645,"href":"https:\/\/csccm.org.cn\/index.php?rest_route=\/wp\/v2\/posts\/24644\/revisions\/24645"}],"wp:attachment":[{"href":"https:\/\/csccm.org.cn\/index.php?rest_route=%2Fwp%2Fv2%2Fmedia&parent=24644"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/csccm.org.cn\/index.php?rest_route=%2Fwp%2Fv2%2Fcategories&post=24644"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/csccm.org.cn\/index.php?rest_route=%2Fwp%2Fv2%2Ftags&post=24644"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}