Early versus late left ventricular unloading during ECMO for cardiogenic shock: A systematic review and meta-analysis_Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

Authors：

PENG Shuyi ¹ , LI Zemeng ¹ , WANG Shuiyun ² , LU Zhengyang ² , HUANG Haibo ¹ , CHANG Shuo ¹ ,  MENG Yanhai ¹ ,  ZHANG Yanbo ¹

1. Division of Surgical Intensive Care Unit, Department of Cardiac Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, 100037, P. R. China;
2. Department of Adult Cardiac Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, 100037, P. R. China;

Corresponding author：

MENG Yanhai, Email: mengyanhai@126.com; ZHANG Yanbo, Email: yanbozhang@126.com

Keywords：

Cardiogenic shock; extracorporeal membrane oxygenation; left ventricular unloading; timing; systematic review / meta-analysis

DOI：

10.7507/1007-4848.202505065

Video：

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Objective To systematically evaluate the effect of the timing of left ventricular (LV) unloading on the outcomes of patients with cardiogenic shock (CS) receiving extracorporeal membrane oxygenation (ECMO). Methods A systematic literature search was conducted in PubMed, EMbase, the Cochrane Library, China National Knowledge Infrastructure (CNKI), SinoMed, and the VIP databases from their inception to February 2025. Literature screening was conducted according to predefined inclusion and exclusion criteria. Two researchers independently assessed the study quality and extracted the data. Patients were divided into an early unloading group and a late unloading group based on the timing of LV unloading. RevMan 5.4 software was used to perform the heterogeneity test and meta-analysis. Results A total of 8 studies involving 2 117 patients were included (1 338 in the early unloading group and 779 in the late unloading group). The meta-analysis showed no statistically significant differences between the two groups in the rates of successful ECMO weaning, in-hospital mortality, or 30-day all-cause mortality (all P>0.05). Compared with the late unloading group, the early unloading group had a lower risk of sepsis [RR=0.79, 95% CI (0.64, 0.96), P=0.02] and abdominal complications [RR=0.67, 95% CI (0.46, 0.96), P=0.03]. Conclusion Compared with late LV unloading, early LV unloading does not significantly improve the successful ECMO weaning rate or early survival. However, early LV unloading is associated with a reduced risk of sepsis and abdominal complications.

1.	Combes A, Price S, Slutsky AS, et al. Temporary circulatory support for cardiogenic shock. Lancet, 2020, 396(10245): 199-212.
2.	Lüsebrink E, Binzenhöfer L, Hering D, et al. Scrutinizing the role of venoarterial extracorporeal membrane oxygenation: has clinical practice outpaced the evidence? Circulation, 2024, 149(13): 1033-1052.
3.	Salter BS, Gross CR, Weiner MM, et al. Temporary mechanical circulatory support devices: practical considerations for all stakeholders. Nat Rev Cardiol, 2023, 20(4): 263-277.
4.	Geller BJ, Sinha SS, Kapur NK, et al. Escalating and de-escalating temporary mechanical circulatory support in cardiogenic shock: a scientific statement from the American Heart Association. Circulation, 2022, 146(6): e50-e68.
5.	Ezad SM, Ryan M, Donker DW, et al. Unloading the left ventricle in venoarterial ECMO: in whom, when, and how? Circulation, 2023, 147(16): 1237-1250.
6.	Eckman PM, Katz JN, El Banayosy A, et al. Veno-arterial extracorporeal membrane oxygenation for cardiogenic shock: an introduction for the busy clinician. Circulation, 2019, 140(24): 2019-2037.
7.	Heidenreich PA, Bozkurt B, Aguilar D, et al. 2022 AHA/ACC/HFSA guideline for the management of heart failure: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation, 2022, 145(18): e895-e1032.
8.	McDonagh TA, Metra M, Adamo M, et al. 2023 focused update of the 2021 ESC guidelines for the diagnosis and treatment of acute and chronic heart failure. Eur Heart J, 2023, 44(37): 3627-3639.
9.	Meani P, Gelsomino S, Natour E, et al. Modalities and effects of left ventricle unloading on extracorporeal life support: a review of the current literature. Eur J Heart Fail, 2017, 19 Suppl 2: 84-91.
10.	Grandin EW, Nunez JI, Willar B, et al. Mechanical left ventricular unloading in patients undergoing venoarterial extracorporeal membrane oxygenation. J Am Coll Cardiol, 2022, 79(13): 1239-1250.
11.	Schrage B, Becher PM, Bernhardt A, et al. Left ventricular unloading is associated with lower mortality in patients with cardiogenic shock treated with venoarterial extracorporeal membrane oxygenation: results from an international, multicenter cohort study. Circulation, 2020, 142(22): 2095-2106.
12.	Kim MC, Lim Y, Lee SH, et al. Early left ventricular unloading or conventional approach after venoarterial extracorporeal membrane oxygenation: the EARLY-UNLOAD randomized clinical trial. Circulation, 2023, 148(20): 1570-1581.
13.	Park H, Yang JH, Ahn JM, et al. Early left atrial venting versus conventional treatment for left ventricular decompression during venoarterial extracorporeal membrane oxygenation support: the EVOLVE-ECMO randomized clinical trial. Eur J Heart Fail, 2023, 25(11): 2037-2046.
14.	Schrage B, Sundermeyer J, Blankenberg S, et al. Timing of active left ventricular unloading in patients on venoarterial extracorporeal membrane oxygenation therapy. JACC Heart Fail, 2023, 11(3): 321-330.
15.	Na SJ, Yang JH, Yang JH, et al. Left heart decompression at venoarterial extracorporeal membrane oxygenation initiation in cardiogenic shock: prophylactic versus therapeutic strategy. J Thorac Dis, 2019, 11(9): 3746-3756.
16.	Piechura LM, Coppolino A, Mody GN, et al. Left ventricle unloading strategies in ECMO: a single-center experience. J Card Surg, 2020, 35(7): 1514-1524.
17.	Radakovic D, Zittermann A, Rojas SV, et al. Left ventricular unloading in patients on venoarterial extracorporeal membrane oxygenation therapy in cardiogenic shock: prophylactic versus bail-out strategy. Life (Basel), 2023, 13(2): 398.
18.	Char S, Fried J, Melehy A, et al. Clinical efficacy of direct or indirect left ventricular unloading during venoarterial extracorporeal membrane oxygenation for primary cardiogenic shock. J Thorac Cardiovasc Surg, 2023, 165(2): 699-707. e5.
19.	Lüsebrink E, Binzenhöfer L, Kellnar A, et al. Venting during venoarterial extracorporeal membrane oxygenation. Clin Res Cardiol, 2023, 112(4): 464-505.
20.	闫阳波, 干昌平. 心源性休克患者外周静脉-动脉体外膜肺氧合支持下左心减压的相关问题. 中国胸心血管外科临床杂志, 2021, 28(9): 1114-1118.Yan YB, Gan CP. Issues on left ventricular decompression during veno-arterial extracorporeal membrane oxygenation in cardiogenic shock patients. Chin J Clin Thorac Cardiovasc Surg, 2021, 28(9): 1114-1118.
21.	Lorusso R, Meani P, Raffa GM, et al. Extracorporeal membrane oxygenation and left ventricular unloading: what is the evidence? JTCVS Tech, 2022, 13: 101-114.
22.	Picado-Loaiza S, Ayala R, Ferreira ROM, et al. Early versus bail-out left ventricular unloading during venoarterial extracorporeal membrane oxygenation: a systematic review and meta-analysis. J Cardiothorac Vasc Anesth, 2025, 39(4): 1015-1025.
23.	Abuelazm M, Nawlo A, Ibrahim AA, et al. Early left ventricular unloading during extracorporeal membrane oxygenation in cardiogenic shock: a systematic review and meta-analysis. Artif Organs, 2025, 49(4): 556-570.
24.	Peña-López Y, Machado MC, Rello J. Infection in ECMO patients: changes in epidemiology, diagnosis and prevention. Anaesth Crit Care Pain Med, 2024, 43(1): 101319.
25.	Gopalakrishnan R, Vashisht R. Sepsis and ECMO. Indian J Thorac Cardiovasc Surg, 2021, 37(Suppl 2): 267-274.
26.	Roumy A, Liaudet L, Rusca M, et al. Pulmonary complications associated with veno-arterial extracorporeal membrane oxygenation: a comprehensive review. Crit Care, 2020, 24(1): 212.
27.	Lüsebrink E, Orban M, Kupka D, et al. Prevention and treatment of pulmonary congestion in patients undergoing venoarterial extracorporeal membrane oxygenation for cardiogenic shock. Eur Heart J, 2020, 41(38): 3753-3761.

1. Combes A, Price S, Slutsky AS, et al. Temporary circulatory support for cardiogenic shock. Lancet, 2020, 396(10245): 199-212.
2. Lüsebrink E, Binzenhöfer L, Hering D, et al. Scrutinizing the role of venoarterial extracorporeal membrane oxygenation: has clinical practice outpaced the evidence? Circulation, 2024, 149(13): 1033-1052.
3. Salter BS, Gross CR, Weiner MM, et al. Temporary mechanical circulatory support devices: practical considerations for all stakeholders. Nat Rev Cardiol, 2023, 20(4): 263-277.
4. Geller BJ, Sinha SS, Kapur NK, et al. Escalating and de-escalating temporary mechanical circulatory support in cardiogenic shock: a scientific statement from the American Heart Association. Circulation, 2022, 146(6): e50-e68.
5. Ezad SM, Ryan M, Donker DW, et al. Unloading the left ventricle in venoarterial ECMO: in whom, when, and how? Circulation, 2023, 147(16): 1237-1250.
6. Eckman PM, Katz JN, El Banayosy A, et al. Veno-arterial extracorporeal membrane oxygenation for cardiogenic shock: an introduction for the busy clinician. Circulation, 2019, 140(24): 2019-2037.
7. Heidenreich PA, Bozkurt B, Aguilar D, et al. 2022 AHA/ACC/HFSA guideline for the management of heart failure: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation, 2022, 145(18): e895-e1032.
8. McDonagh TA, Metra M, Adamo M, et al. 2023 focused update of the 2021 ESC guidelines for the diagnosis and treatment of acute and chronic heart failure. Eur Heart J, 2023, 44(37): 3627-3639.
9. Meani P, Gelsomino S, Natour E, et al. Modalities and effects of left ventricle unloading on extracorporeal life support: a review of the current literature. Eur J Heart Fail, 2017, 19 Suppl 2: 84-91.
10. Grandin EW, Nunez JI, Willar B, et al. Mechanical left ventricular unloading in patients undergoing venoarterial extracorporeal membrane oxygenation. J Am Coll Cardiol, 2022, 79(13): 1239-1250.
11. Schrage B, Becher PM, Bernhardt A, et al. Left ventricular unloading is associated with lower mortality in patients with cardiogenic shock treated with venoarterial extracorporeal membrane oxygenation: results from an international, multicenter cohort study. Circulation, 2020, 142(22): 2095-2106.
12. Kim MC, Lim Y, Lee SH, et al. Early left ventricular unloading or conventional approach after venoarterial extracorporeal membrane oxygenation: the EARLY-UNLOAD randomized clinical trial. Circulation, 2023, 148(20): 1570-1581.
13. Park H, Yang JH, Ahn JM, et al. Early left atrial venting versus conventional treatment for left ventricular decompression during venoarterial extracorporeal membrane oxygenation support: the EVOLVE-ECMO randomized clinical trial. Eur J Heart Fail, 2023, 25(11): 2037-2046.
14. Schrage B, Sundermeyer J, Blankenberg S, et al. Timing of active left ventricular unloading in patients on venoarterial extracorporeal membrane oxygenation therapy. JACC Heart Fail, 2023, 11(3): 321-330.
15. Na SJ, Yang JH, Yang JH, et al. Left heart decompression at venoarterial extracorporeal membrane oxygenation initiation in cardiogenic shock: prophylactic versus therapeutic strategy. J Thorac Dis, 2019, 11(9): 3746-3756.
16. Piechura LM, Coppolino A, Mody GN, et al. Left ventricle unloading strategies in ECMO: a single-center experience. J Card Surg, 2020, 35(7): 1514-1524.
17. Radakovic D, Zittermann A, Rojas SV, et al. Left ventricular unloading in patients on venoarterial extracorporeal membrane oxygenation therapy in cardiogenic shock: prophylactic versus bail-out strategy. Life (Basel), 2023, 13(2): 398.
18. Char S, Fried J, Melehy A, et al. Clinical efficacy of direct or indirect left ventricular unloading during venoarterial extracorporeal membrane oxygenation for primary cardiogenic shock. J Thorac Cardiovasc Surg, 2023, 165(2): 699-707. e5.
19. Lüsebrink E, Binzenhöfer L, Kellnar A, et al. Venting during venoarterial extracorporeal membrane oxygenation. Clin Res Cardiol, 2023, 112(4): 464-505.
20. 闫阳波, 干昌平. 心源性休克患者外周静脉-动脉体外膜肺氧合支持下左心减压的相关问题. 中国胸心血管外科临床杂志, 2021, 28(9): 1114-1118.Yan YB, Gan CP. Issues on left ventricular decompression during veno-arterial extracorporeal membrane oxygenation in cardiogenic shock patients. Chin J Clin Thorac Cardiovasc Surg, 2021, 28(9): 1114-1118.
21. Lorusso R, Meani P, Raffa GM, et al. Extracorporeal membrane oxygenation and left ventricular unloading: what is the evidence? JTCVS Tech, 2022, 13: 101-114.
22. Picado-Loaiza S, Ayala R, Ferreira ROM, et al. Early versus bail-out left ventricular unloading during venoarterial extracorporeal membrane oxygenation: a systematic review and meta-analysis. J Cardiothorac Vasc Anesth, 2025, 39(4): 1015-1025.
23. Abuelazm M, Nawlo A, Ibrahim AA, et al. Early left ventricular unloading during extracorporeal membrane oxygenation in cardiogenic shock: a systematic review and meta-analysis. Artif Organs, 2025, 49(4): 556-570.
24. Peña-López Y, Machado MC, Rello J. Infection in ECMO patients: changes in epidemiology, diagnosis and prevention. Anaesth Crit Care Pain Med, 2024, 43(1): 101319.
25. Gopalakrishnan R, Vashisht R. Sepsis and ECMO. Indian J Thorac Cardiovasc Surg, 2021, 37(Suppl 2): 267-274.
26. Roumy A, Liaudet L, Rusca M, et al. Pulmonary complications associated with veno-arterial extracorporeal membrane oxygenation: a comprehensive review. Crit Care, 2020, 24(1): 212.
27. Lüsebrink E, Orban M, Kupka D, et al. Prevention and treatment of pulmonary congestion in patients undergoing venoarterial extracorporeal membrane oxygenation for cardiogenic shock. Eur Heart J, 2020, 41(38): 3753-3761.

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