National Practice Patterns of VA ECMO and Left Ventricular Mechanical Unloading for Cardiogenic Shock

Cardiogenic shock (CS) remains highly morbid despite significant advancements in management. A cornerstone of this management is Venoarterial Extracorporeal Membrane Oxygenation (VA ECMO). However, consensus surrounding the management of VA ECMO for CS, including the use of concomitant Left Ventricular Mechanical Unloading (LVMU), remains limited.

We thus conducted a national survey of practice patterns in the treatment of CS to characterize such variability. Surveys were distributed to physicians involved in management of VA ECMO across a variety of center types.

Responses representing 67 institutions were analyzed. VA ECMO was used for a median of 10% of CS patients at each institution. Formal shock teams were present at 64.1% of centers and were associated with both higher annual VA ECMO volume (P⟨0.01) and greater intra-aortic balloon pump use prior to VA ECMO (p = 0.03). LVMU was employed by 63.4% of centers, most commonly using Impella (93.3%), with unloading initiated at ECMO cannulation in a median of 30% of cases. Triggers and targets for LVMU varied widely, though pulmonary capillary wedge pressure was the most common endpoint.

These findings highlight substantial heterogeneity in CS diagnosis, VA ECMO initiation, and LVMU strategies, underscoring the need for prospective studies to define optimal care.