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Purpose: Cardiogenic shock is associated with high mortality. In refractory shock, it is unclear if mechanical circulatory support (MCS) devices improve survival. We conducted a network meta-analysis to determine which MCS devices confers greatest benefit. Methods: We searched MEDLINE, Embase, and Scopus databases through 27 August 2023 for relevant randomized controlled trials (RCTs) and propensity score-matched studies (PSMs). We conducted frequentist network meta-analysis, investigating mortality (either 30 days or in-hospital) as the primary outcome. We assessed risk of bias (Cochrane risk of bias 2.0 tool/Newcastle–Ottawa Scale) and as sensitivity analysis reconstructed survival data from published survival curves for a one-stage unadjusted individual patient data (IPD) meta-analysis using a stratified Cox model. Results: We included 38 studies (48,749 patients), mostly reporting on patients with Society for Cardiovascular Angiography and Intervention shock stages C–E cardiogenic shock. Compared with no MCS, extracorporeal membrane oxygenation with intra-aortic balloon pump (ECMO-IABP; network odds ratio [OR]: 0.54, 95% confidence interval (CI): 0.33–0.86, moderate certainty) was associated with lower mortality. There were no differences in mortality between ECMO, IABP, microaxial ventricular assist device (mVAD), ECMO-mVAD, centrifugal VAD, or mVAD-IABP and no MCS (all very low certainty). Our one-stage IPD survival meta-analysis based on the stratified Cox model found only ECMO-IABP was associated with lower mortality (hazard ratio, HR, 0.55, 95% CI 0.46–0.66). Conclusion: In patients with cardiogenic shock, ECMO-IABP may reduce mortality, while other MCS devices did not reduce mortality. However, this must be interpreted within the context of inter-study heterogeneity and limited certainty of evidence. [ABSTRACT FROM AUTHOR]

Background: A strategy that limits tidal volumes and inspiratory pressures, improves outcomes in patients with the acute respiratory distress syndrome (ARDS). Extracorporeal carbon dioxide removal (ECCO2R) may facilitate ultra-protective ventilation. We conducted a systematic review and meta-analysis to evaluate the efficacy and safety of venovenous ECCO2R in supporting ultra-protective ventilation in moderate-to-severe ARDS. Methods: MEDLINE and EMBASE were interrogated for studies (2000–2021) reporting venovenous ECCO2R use in patients with moderate-to-severe ARDS. Studies reporting ≥10 adult patients in English language journals were included. Ventilatory parameters after 24 h of initiating ECCO2R, device characteristics, and safety outcomes were collected. The primary outcome measure was the change in driving pressure at 24 h of ECCO2R therapy in relation to baseline. Secondary outcomes included change in tidal volume, gas exchange, and safety data. Results: Ten studies reporting 421 patients (PaO2:FiO2 141.03 mmHg) were included. Extracorporeal blood flow rates ranged from 0.35-1.5 L/min. Random effects modelling indicated a 3.56 cmH2O reduction (95%-CI: 3.22–3.91) in driving pressure from baseline (p <.001) and a 1.89 mL/kg (95%-CI: 1.75–2.02, p <.001) reduction in tidal volume. Oxygenation, respiratory rate and PEEP remained unchanged. No significant interactions between driving pressure reduction and baseline driving pressure, partial pressure of arterial carbon dioxide or PaO2:FiO2 ratio were identified in metaregression analysis. Bleeding and haemolysis were the commonest complications of therapy. Conclusions: Venovenous ECCO2R permitted significant reductions in ∆P in patients with moderate-to-severe ARDS. Heterogeneity amongst studies and devices, a paucity of randomised controlled trials, and variable safety reporting calls for standardisation of outcome reporting. Prospective evaluation of optimal device operation and anticoagulation in high quality studies is required before further recommendations can be made. [ABSTRACT FROM AUTHOR]

Veno-arterial extra corporeal membrane oxygenation (VA-ECMO) is a modified heart lung machine used for patients with both heart and lung failure. This results in retrograde supply of oxygenated blood through the femoral artery in which the unsteady pulsating antegrade flow from the aorta interacts with a steady, uniform, and retrograde flow from the femoral artery, creating a mixing zone. This work aims to provide a mechanistic interpretation of VA-ECMO by developing an in-silico framework using computational fluid dynamics. We performed several numerical simulations to investigate the effects of aortic geometry on VA-ECMO by implementing two idealized full aorta models and studied the formation of secondary flow features and vortices. We used vortex identification methods to capture the three-dimensional vortical structures formed under various ECMO support levels. Our results show that under pulsatile aortic flow and 80% of ECMO support, the streamwise vorticity and aortic arch geometry strongly influence the mixing zone. Furthermore, we found that pulsatility at the aortic inlet causes oscillation in secondary flow structures at the abdominal aorta leading to unsteadiness in ECMO flow and differential wall shear stress. We also examined the effects of VA-ECMO flow rates on secondary flow and vortical structures. We show that the location and complexity of secondary flows and vortical structures are affected by ECMO support levels and geometry of aortic segments. Together, we believe that this computational framework is a crucial step in understanding flow features and vortical structures formed during VA-ECMO administration, which can improve patient care and ECMO management. [ABSTRACT FROM AUTHOR]