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MCC 260405

REVIEW

CURRENT
OPINION The place of extracorporeal life support in
cardiogenic shock
Marc Pineton de Chambrun a,b, Nicolas Bréchot a,b, and Alain Combes a,b

Purpose of review
Temporary circulatory support (TCS) devices are increasingly used as a salvage therapy for patients with
refractory cardiogenic shock. The exact place of the different TCS devices in the management of
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cardiogenic shock patients remains unclear and intensely debated. This article provides an overview on
new cardiogenic shock classification, currently available devices, place of TCS in the management of
cardiogenic shock patients, and discusses the results of recent case series and trials in this setting.
Recent finding
A new classification system for cardiogenic shock has recently been proposed to homogenize definitions of
cardiogenic shock and appropriately differentiate patient subsets in clinical trials and registries. Although
the routine use of intraaortic balloon pump is no more recommended a other TCS are increasingly used
and investigated but many advantages favor the use of venoarterial extracorporeal membrane oxygenation
(VA-ECMO) as the first-line TCS.
Summary
TCS devices have become the cornerstone of the management of patients with refractory cardiogenic
shock. VA-ECMO has emerged as the first-line support system in this setting, with a growing number of
accepted indications. Large adequately powered randomized controlled trials are now underway and
should help to determine the respective place of different TCS devices in strategies to treat cardiogenic
shock patients.
Keywords
cardiogenic shock, intraaortic balloon pump, temporary circulatory support, venoarterial extracorporeal
membrane oxygenation

INTRODUCTION &
[7,8 ]. Four adequately powered randomized con-
Temporary circulatory support (TCS) devices trolled trials are now underway to evaluate Impella
have become the cornerstone of the management device (NCT01633502) and venoarterial extracor-
of patients with refractory cardiogenic shock, poreal membrane oxygenation (VA-ECMO,
although their use only received a Class IIb rec- NCT03813134, NCT03637205, NCT04184635) in
ommendation from the European Society of Car- cardiogenic shock complicating AMI.
diology (ESC) [1,2]. The intraaortic balloon pump
(IABP) is now not recommended for routine use in
acute myocardial infarction (AMI) cardiogenic
shock by ESC guidelines, since the large IABP-
SHOCK II trial, which randomized 600 patients
a
with cardiogenic shock complicating AMI, found Service de Médecine Intensive-Réanimation, Institut de Cardiologie,
APHP Hôpital Pitié-Salpêtrière and bSorbonne Université, INSERM,
no difference in mortality and any of the second-
UMRS_1166-ICAN, Institute of Cardiometabolism and Nutrition, Paris,
ary study endpoints between IABP or conventional France
treatment [3–6]. More recently, two large propen- Correspondence to Alain Combes, Service de Médecine Intensive-
sity-matched case-controlled series showed that Réanimation, Institut de Cardiologie, APHP Hôpital Pitié-Salpêtrière,
routine treatment with an intravascular micro F-75013 Paris, France. Tel: +33 1 42 16 38 16;
axial left ventricle assisting device (LVAD) was also fax: +33 1 42 16 38 17; e-mail: [email protected]
not associated with lower 30-day all-cause mortal- Curr Opin Crit Care 2020, 26:000–000
ity compared with matched patients with IABP DOI:10.1097/MCC.0000000000000747

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Cardiogenic shock

patients with cardiogenic shock. It also intended

KEY POINTS to homogenize definitions of cardiogenic shock to
 A new classification system for cardiogenic shock has appropriately differentiate patient subsets in clinical
been recently proposed by the Society for trials and registries. In a cohort of 10 000 patients
Cardiovascular Angiography and Intervention. admitted to a cardiac intensive care unit, the SCAI
cardiogenic shock scores stages A–E frequencies at
 VA-ECMO is the first-line temporary circulatory support
admission were 46.0, 30.0, 15.7, 7.3, and 1.0% with
in patients with refractory cardiogenic shock, with a
growing number of accepted indications. an associated hospital mortality of 3.0, 7.1, 12.4,
&&
40.4, and 67% (P < 0.001), respectively [14 ]. Thus,
 Impella and intraaortic balloon pump may be SCAI classification provides a robust risk prognosis
associated with VA-ECMO to decrease left ventricle stratification in cardiogenic shock patients.
pressures and improve outcomes.
 Sepsis-associated cardiomyopathy, massive pulmonary
embolism, and refractory cardiac arrest are among THE PLACE OF TEMPORARY
emerging indications for VA-ECMO. CIRCULATORY SUPPORT IN
CARDIOGENIC SHOCK
 Large, adequately powered, randomized clinical trials
are now underway to determine the respective place of
different temporary circulatory support devices in
Intraaortic balloon pump
strategies to treat cardiogenic shock patients. The IABP-SHOCK II trial, which randomized 600
patients with cardiogenic shock complicating
AMI, found no difference in mortality and any of
the secondary study endpoints between IABP or
CARDIOGENIC SHOCK: DEFINITION AND conventional treatment [3,5,6]. These results led
CLASSIFICATION to a downgrading of the IABP in the ESC guidelines
with a current class IIIB recommendation against
Definition the routine use of the IABP in cardiogenic shock,
Cardiogenic shock is defined as a state of critical although the IABP may still be considered in
end-organ hypoperfusion and hypoxia because of patients with AMI mechanical complications (class
primary cardiac dysfunction [9]. The diagnosis IIa, level C) [1].
of cardiogenic shock can be made on the basis of
clinical criteria (hypotension, pulmonary conges-
tion, cold extremities, oliguria, altered mental Percutaneous active temporary circulatory
status, etc.), biochemical findings of inadequate support devices
tissue perfusion (acute kidney insufficiency, Since the publication of the negative results of the
hypoxic hepatitis, elevated arterial lactate, etc.) IABP-Shock II trial, percutaneous active TCS are
and hemodynamic parameters (reduced cardiac increasingly used [15]. Current devices include the
index and elevated pulmonary capillary wedge pres- TandemHeart (TandemLife, Pittsburgh, PA, USA)
sure). However, the ESC guidelines definition of which is a percutaneous LVAD consisting of an
cardiogenic shock [1] and these applied in the major extracorporeal centrifugal continuous flow pump
randomized trials [3,10–12] focusing on cardiogenic that drains blood from the left atrium via a cannula
shock are heterogenous (Table 1). introduced transseptally through the femoral vein.
Blood is then pumped back to the femoral artery at a
&
flow rate of up to 3.5 l/min [8 ,23]. The Impella 2.5,
New Society for Cardiovascular Angiography CP, or 5.0 (ABIOMED Inc., Danvers, MA, USA) are
and Intervention classification catheter-based axial flow pumps with a propeller at
Patients with cardiogenic shock represent a hetero- the tip of the catheter which is positioned retro-
geneous population with varying prognosis based gradely across the aortic valve into the left ventricle.
on severity of illness, cause, and comorbidities. The Impella devices directly vent the left ventricle and
Society for Cardiovascular Angiography and Inter- provide more physiologic support than VA-ECMO,
vention (SCAI) recently proposed a new cardiogenic which increases left ventricle afterload [16–20].
shock classification featuring five stages (A–E) of However, the evidence supporting the use of these
increasing severity based on clinical, biological, devices in cardiogenic shock is limited. Indeed, a
and hemodynamic signs of cardiogenic shock meta-analysis including four trials randomizing 148
&&
(Table 2) [13 ]. The purpose of this initiative was patients to either TandemHeartTM or Impella
to provide a simple tool for bedside evaluation, (n ¼ 77) versus IABP (n ¼ 71) showed no difference
prognostication, and treatment optimization of in 30-day mortality [15]. More recently, a study of

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The place of extracorporeal life support in cardiogenic shock Pineton de Chambrun et al.

Table 1. Definition of cardiogenic shock in ESC guidelines and major randomized clinical trialsa
Title Diagnosis/inclusion criteria Ref

ESC guidelines SBP < 90 mmHg with adequate volume and II or III [1]
Clinical hypoperfusion: Cold extremities, oliguria, mental confusion, dizziness, and narrow pulse pressure
Laboratory hypoperfusion: metabolic acidosis, elevated lactate, elevated creatinine
SHOCK trial SBP < 90 mmHg for 30 min or support to maintain SBP  90 mmHg [11]
Endorgan hypoperfusion (urine output < 30 ml/h or cool extremities and heart rate >60 bpm)
Hemodynamic criteria: cardiac index of 2.2 l/min/m2 and PCWP  15 mmHg
TRIUMPH trial Patency of IRA spontaneously or after PCI [10]
Refractory cardiogenic shock > 1 h after PCI with SBP < 100 mmHg despite vasopressors
(dopamine  7 mg/kg/min or norepinephrine or epinephrine  0.15 mg/kg/min)
Endorgan hypoperfusion
Clinical or hemodynamic criteria for elevated left ventricle filling pressure
LVEF < 40%
IABP-Shock II trial SBP < 90 mmHg for 30 min or catecholamines to maintain SBP > 90 mmHg [3]
Clinical pulmonary congestion
Impaired organ perfusion with at least one of the following:
Altered mental status
Cold/clammy skin and extremities
Urine output < 30 ml/h
Lactate >2.0 mmol/l
CULPRIT-Shock trial Planned early revascularization by PCI [12]
Multivessel CAD defined as >70% stenosis in at least two major vessels (2 mm diameter) with
identifiable culprit lesion
SBP < 90 mmHg for >30 min or catecholamines required to maintain SBP > 90 mmHg
Pulmonary congestion
Impaired organ perfusion with at least one of the following:
Altered mental status
Cold/clammy skin and extremities
Urine output <30 ml/h
Lactate > 2.0 mmol/l
DAN-Shock trial STEMI of less than 36 h duration NCT01633502
Cardiogenic shock of less than 24 h duration
SBP < 100 mmHg and/or need for vasopressor therapy
Peripheral signs of tissue hypoperfusion:
Lactate  2.5 mmol/l
SvO2 < 55% with a normal PaO2
LVEF<45% visually estimated or by wall motion score index > 1.6
ECLS-Shock trial Cardiogenic shock complicating STEMI or NSTEMI NCT03637205
Planned revascularization (PCI or alternatively CABG)
SBP <90 mmHg for >30 min or catecholamines required to maintain pressure SBP > 90 mmHg
Signs of impaired organ perfusion with at least one of the following:
Altered mental status
Cold/clammy skin and extremities
Urine output < 30 ml/h
Arterial lactate >3 mmol/l
EURO-Shock trial Cardiogenic shock within 24 h of onset of ACS symptoms NCT03813134
CGS can only be secondary to ACS (Type 1 MI STEMI or N-STEMI) or secondary to ACS following
previous recent PCI
PCI has been attempted
Persistence of cardiogenic shock >30 min after successful or unsuccessful revascularization of culprit
coronary artery
SBP < 90 mmHg for >30 min, or vasopressor/inotropic therapy to maintain SBP > 90 mmHg
Clinical signs of pulmonary congestion
Signs of impaired organ perfusion with at least one of the following:
Altered mental status
Cold/clammy skin and extremities
Urine output < 30 ml/h
Serum lactate > 2.0 mmol/l
ANCHOR trial Cardiogenic shock complicating acute myocardial infarction NCT04184635
Revascularization by PCI for acute myocardial infarction has been performed or is planned in the following
60 min
SBP < 90 mmHg for >30 min or catecholamine support required to maintain SBP > 90 mmHg
Signs of pulmonary congestion
Signs of impaired organ perfusion with at least one of the following:
Altered mental status
Cold/clammy skin and extremities
Urine output < 30 ml/h
Serum lactate > 2.0 mmol/l

ACS, acute coronary syndrome; CABG, coronary artery bypass graft; CAD, coronary artery disease; ESC, European Society of Cardiology; IABP, intraaortic
balloon conterpulsation; IRA, infarction related artery; LVEF, left ventricle ejection fraction; NSTEMI, non-ST-elevation myocardial infarction; PCI, percutaneous
coronary intervention; PCWP, pulmonary capillary wedge pressure; SBP, systolic blood pressure; STEMI, ST-elevation myocardial infarction.
a &&
Adapted from [33 ].

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Cardiogenic shock

Table 2. The Society for Cardiovascular Angiography and Intervention (SCAI) cardiogenic shock classificationa

Stage Description Physical exam Biochemical markers Hemodynamics

A Patients at risk for Normal JVP Normal lactic acid Normal blood pressure
At risk cardiogenic shock Normal physical exam Normal renal function If hemodynamics done:
(i.e., large Cardiac index  2.5
myocardial CVP < 10
infarction, etc.) Pulmonary artery
saturation  65%
B Relative hypotension or Elevated JVP Normal lactic acid SBP < 90 OR MAP < 60
Beginning tachycardia without Rales in lung fields Minimal renal OR drop > 30 mmHg
hypoperfusion No sign of peripheral function impairment from baseline
hypoperfusion Elevated BNP Pulse > 100 bpm
If hemodynamics done:
Cardiac index  2.2
Pulmonary artery
saturation  65%
C Hypoperfusion May include any of: May include any of: May include any of:
Classic requirering Look unwell, panicked Lactate  2 SBP < 90 OR MAP < 60
intervention beyond Ashen, mottled, dusky Creatinine doubling OR drop > 30 mmHg
volume resuscitation Cold, clammy >50% drop in GFR from baseline
to restore perfusion Volume overload Elevated LFTs AND
(inotrope, pressors or Extensive rales Elevated BNP Need for drugs/device
TCS) Killip class 3 or 4 used to maintain blood
NIV or mechanical pressure above
ventilation These targets
Altered mental status Hemodynamics:
Urine output < 30 ml/h Cardiac index < 2.2
PCWP > 15
RAP/PCWP  0.8
PAPI < 1.85
Cardiac power
output  0.6
D Deteriorating/ Similar to category C Any of stage C Any of stage C Any of Stage C
Doom but getting worse AND AND
Failure to respond to Deteriorating Need for multiple pressors
initial interventions or TCS devices to
maintain perfusion
E Cardiac arrest with Near pulselessness CPR No SBP without
Extremis ongoing CPR and/or Cardiac collapse pH  7.2 resuscitation
ECMO Mechanical ventilation Lactate  5 PEA or refractory
Multiple ongoing Defibrillator used ventricular tachycardia/
intervention ventricular fibrillation
Hypotension despite
maximal support

BNP, Brain natriuretic peptide; CPR, cardiopulmonary resuscitation; CVP, central venous pressure; ECMO, extracorporeal membrane oxygenation; GFR,
glomerular filtration rate; JVP, jugular venous pressure; LFTs, liver function tests; MAP, mean arterial pressure; NIV, noninvasive ventilation; PAPI, pulmonary artery
pulsatility index; PCWP, pulmonary capillary wedge pressure; PEA, pulseless electric activity; RAP, right arterial pressure; SBP, systolic blood pressure; SCAI,
Society for Cardiovascular Angiography and Intervention; TCS, temporary circulatory support.
a &&
Adapted from [13 ].

237 AMI patients who received the Impella propen- interval (CI)] ¼ 1.17 [1.10–1.24], P < 0.001) [21]. The
sity-matched with 237 patients from the IABP- rates of serious adverse events, including infections,
SHOCK II trial, there was no significant difference stroke, and bleeding were more frequent in patients
in 30-day all-cause mortality (49 versus 46%, receiving the Impella [7,21]. Another propensity-
P ¼ 0.64) [7]. In a large-scale registry study including matched registry-based retrospective cohort study
48 306 patients of whom 50% had cardiogenic including patients with AMI complicated by cardio-
shock, undergoing percutaneous coronary interven- genic shock undergoing PCI between October 1,
tion (PCI) with TCS support at 432 hospitals in the 2015 and December 31, 2017 compared intravascu-
USA, the use of Impella was even associated with lar microaxial LVAD (mostly Impella) to IABP.
increased mortality (adjusted OR [95% confidence Patients were matched on demographics, clinical

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The place of extracorporeal life support in cardiogenic shock Pineton de Chambrun et al.

history, presentation, infarct location, coronary anat- particularly in patients with marked left ventricle
omy, and clinical laboratory data. Among 1680 pro- dilation and very low spontaneous residual
pensity-matched pairs, there was a significantly ejection under VA-ECMO (aortic velocity–time inte-
higher risk of in-hospital death associated with use gral < 5 cm) [29,30]. In a Meta-analysis including 17
of an intravascular microaxial LVAD compared with studies and 3997 patients, mortality was lower (54
IABP (45.0 versus 34.1%, absolute risk difference, versus 65%, RR 0.79, 95% CI [0.72–0.87]; P < 0.00001)
10.9% [95% CI, 7.6–14.2], P < 0.001, respectively) in patients with concomitant left ventricle unloading
and also higher risk of in-hospital major bleeding which most frequently combined VA-ECMO and
&
(31.3 versus 16.0%, absolute risk difference, 15.4% IABP [31 ]. Another meta-analysis included 62 obser-
&
[95% CI, 12.5–18.2], P < 0.001) [8 ]. A large random- vational studies and 7995 patients wherein 3458
ized trial comparing the Impella CP against conven- received left ventricle venting during VA-ECMO
tional treatment in 360 AMI cardiogenic shock (mainly IABP and Impella device). Left ventricle vent-
patients is now ongoing (NCT01633502). ing significantly improved weaning from VA-ECMO
(68.4 versus 46.7%, OR 0.62 [95% CI, 0.47–0.83];
P ¼ 0.001) and reduced 30-day mortality (50.9 versus
Venoarterial extracorporeal membrane 60.2%; RR 0.86 [95% CI, 0.77–0.96]; P ¼ 0.008). Inter-
oxygenation estingly only early venting was significantly reduced
&&
VA-ECMO has become the first-line therapy in the 30-day mortality [32 ]. Future randomized studies
setting of cardiogenic shock, as it provides both are warranted to determine if these combination
respiratory and cardiac support, is easy to insert, even strategies are superior to stand-alone devices.
at the bedside, provides stable flow rates, and is
associated with less organ failure after implantation
compared with large biventricular assist-devices RECENT EVIDENCE IN SELECTED
that require open-heart surgery [22–25]. With the INDICATIONS
improvement of biomaterials and technologies, VA-
ECMO can now stay in place several days or even Acute myocardial infarction
weeks, as a bridge to ‘decision’ that includes recovery, AMI is the most frequent cause of cardiogenic shock,
transplantation, long-term mechanical circulatory representing up to 70% of cases and occurring in 5–
support or withdrawal in case of futility [15,26]. 10% of patients with AMI. Despite major therapeutic
Compared with percutaneous active TCS devices, advances, mortality of cardiogenic shock in the set-
VA-ECMO is less expensive, allows rapid improve- ting of AMI remained unacceptably high (40–50%)
&&
ment in oxygenation and is the only short-term in recent years [33 ]. In a large US national database
device suitable for patients with severe biventricular spanning from 2000 to 2014, a steady increase was
failure. However, guidelines from the ESC (Class IIb, identified in the utilization of VA-ECMO among
Level of Evidence C) recommended that TCS implan- patients with AMI. In approximatively 9 million
tation should only be considered in selected cardio- AMI admissions, VA-ECMO was used in 2962
genic shock patients [27]. High-grade scientific (<0.01%) and in 0.5 and 0.3% AMI admissions com-
evidence supporting the use of VA-ECMO in cardio- plicated by cardiogenic shock and cardiac arrest,
genic shock is urgently awaited [28]. Three large, respectively. VA-ECMO use was 11 times higher in
adequately powered randomized controlled trials 2014 as compared with 2000 (odds ratio, 11.37 [95%
(NCT03813134, NCT03637205, NCT04184635) cur- CI, 7.20–17.97]) whereas in-hospital mortality with
rently underway should clarify the role of VA-ECMO VA-ECMO was 59.2% overall but decreased from
&
in AMI patients with cardiogenic shock. 100% (in 2000) to 45.1% (in 2014) [34 ]. A study
comparing patients with refractory cardiogenic shock
complicating ST-segment elevation AMI implanted
Left ventricle unloading: combining with VA-ECMO before (n ¼ 12) or after (n ¼ 34) PCI
intraaortic balloon pump or Impella to reported an improved 6-month survival (58.3% versus
venoarterial extracorporeal membrane 14.7%, P ¼ 0.006) in patients with early VA-ECMO
oxygenation? implantation. However, the proportion of patients
As VA-ECMO provides retrograde blood flow in the achieving door-to-balloon time <90 min was lower
aorta, it increases left ventricle afterload, may decrease (9.1 versus 32%) [35]. In 106 consecutive patients
or abolish heart ejection and may induce pulmonary implanted with VA-ECMO around PCI for refractory
edema by increasing left ventricle end-diastolic pres- cardiogenic shock, the implantation of VA-ECMO
sure [29,30]. Combining IABP and VA-ECMO support before or during PCI granted the most favorable
may decrease left ventricle pressures and the 30-day survival compared with implantation after
occurrence of pulmonary edema under VA-ECMO, PCI [36].

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Cardiogenic shock

Massive pulmonary embolism CPR group, factors associated with hospital survival
Some patients with massive pulmonary embolism were initial shockable rhythm (OR, 3.9; 95% CI,
(MPE) will develop right ventricular failure, hypox- 1.5–10.3; P ¼ 0.005), transient return on spontane-
emia, and severe hemodynamic instability. In this ous circulation before VA-ECMO (OR, 2.3; 95% CI,
setting, VA-ECMO might lower their RV overload, 1.1–4.7; P ¼ 0.03), and prehospital VA-ECMO
improve hemodynamic status, and restore tissue implantation (OR, 2.9; 95% CI, 1.5–5.9; P ¼ 0.002)
&

oxygenation [37]. However, whether VA-ECMO [43 ]. VA-ECMO might also be initiated in the case
should be used as a stand-alone therapy or associated of postcardiac arrest cardiogenic shock. In a series
with surgical or catheter-based embolectomy is still reporting the outcomes of 94 patients implanted
debated. In a large series of 180 MPE, 52 patients with VA-ECMO in this setting, hospital and 12-
received VA-ECMO: as a standalone therapy (n ¼ 18), month survival rates were 28 and 27%, respectively,
after failed fibrinolysis (n ¼ 20) or before/after and all one-year survivors were cerebral perfor-
embolectomy (n ¼ 7/n ¼ 10). Mortality was higher mance category 1 [44].
in patients that required VA-ECMO implantation
(ECMO group: 62% versus no-ECMO group: 43%,
Sepsis-associated cardiomyopathy
P ¼ 0.008); however, patients in the VA-ECMO and
embolectomy group (30-day mortality 29%) had the Profound myocardial depression may develop
&&
most favorable outcome [38 ]. In a series of 41 con- because of severe septic shock. Recent data sug-
secutive patients with MPE managed using a proto- gested that VA-ECMO may rescue patients who
colized approach in which RV function was evaluated develop refractory cardiac failure in this setting
3–5 days after VA-ECMO support a only patients with [45,46]. Larger studies are now needed to determine
unrecovering RV function underwent surgical embo- whether the benefit of VA-ECMO outweighs the
lectomy. Using this approach, 73% responded to risks, especially in cases where septic shock is com-
anticoagulation alone and 27% required surgical plicated by marked disturbances in coagulation.
embolectomy with an overall 90-day survival of
&&
97 and 100%, respectively [39 ]. Another team estab-
Hypothermic cardiac arrest
lished an MPE protocol in which VA-ECMO was
favored to thrombolytic therapy in patients Patients with accidental hypothermia without vital
who remained in cardiogenic shock or under cardio- signs increasingly receive VA-ECMO; however, there
pulmonary resuscitation (CPR) despite supportive is limited knowledge regarding the efficacy of this
measures. After VA-ECMO implantation, surgical rewarming method. In a large nationwide inpatient
embolectomy was the preferred strategy for all database in Japan from July 2010 to March 2017,
patients. Over 36 consecutive patients, 25% died patients with accidental hypothermia receiving CPR
under VA-ECMO, 19% could be weaned from VA- were compared according to the use of VA-ECMO on
ECMO with a 71.4% survival and 56% underwent the day of admission. Over 1661 eligible patients,
surgical embolectomy with a 94.7% survival [40 ].
&
318 (19%) received VA-ECMO on the day of admis-
Future randomized studies are warranted to sion resulting in 300 propensity-matched pair of
determine the best strategy for MPE patients under patients. In-hospital mortality was significantly
VA-ECMO. lower (risk difference: 13% [95% CI, 5.1–21%])
and the proportion of patients with ‘alert conscious-
ness’ at discharge was higher (risk difference: 8.3%
Cardiac arrest [95% CI, 1.9–15%]) in the VA-ECMO group com-
VA-ECMO support to restore circulation during car- pared with the conventional CPR [47]. The HOPE
diac arrest is known as extracorporeal CPR (E-CPR). score is based on six independent covariates avail-
Although there are no randomized controlled trials able at admission and allows to predict in-hospital
reporting the efficacy of E-CPR, its use has been survival of accidental hypothermia receiving CPR. It
steadily increasing [41], despite being the subject was recently validated in an external prospective
of controversies [42]. In a population-based registry, cohort of 122 patients. The empirical probability
including 13 191 out-of-hospital cardiac arrest from of survival was 42% (95% CI, 33–51%) and the
Paris region, between May 2011 and January 2018, Hosmer–Lemeshow test comparing empirical and
4% (n ¼ 525) were treated with E-CPR which was not HOPE probabilities of survival was not significant
associated with increased hospital survival (E-CPR (P ¼ 0.08), suggesting good calibration. The area
8%, conventional-CPR 9%, P ¼ 0.91). E-CPR was not under the receiver operating characteristic curve
associated with hospital survival after adjusted mul- was 0.825 (95% CI, 0.753–0.897), confirming the
tivariate analysis, after conditional logistic regres- excellent discrimination of the model. The negative
sion with matching on a propensity score. In the E- predictive value of a HOPE score cut-off of less than

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arrest. Median duration of VA-ECMO was 68 [IQR This large registry-based propensity-matched retrospective study found no benefit
25–75; 48–113] and 52.9% of the cases survived to of survival and more bleeding complication of intravascular micro axial left ventricle
assisting device compared with intraaortic balloon pump but also of intraaortic
discharge [49]. balloon pump compared with conventional treatment.
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management of patients with refractory cardiogenic 11. Hochman JS, Sleeper LA, Webb JG, et al. Early revascularization in acute
shock, although their use only received a Class IIb myocardial infarction complicated by cardiogenic shock. SHOCK Investiga-
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&&
Cardiology [13 ]. Because it is less expensive than 12. Thiele H, Akin I, Sandri M, et al. PCI strategies in patients with acute
myocardial infarction and cardiogenic shock. N Engl J Med 2017;
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&& statement on the classification of cardiogenic shock: this document was
patients with severe biventricular failure, VA-ECMO endorsed by the American College of Cardiology (ACC), the American Heart
has emerged as the first-line support system in this Association (AHA), the Society of Critical Care Medicine (SCCM), and the
Society of Thoracic Surgeons (STS) in April. Catheter Cardiovasc Interv
setting, with a growing number of indications. Ran- 2019; 94:29–37.
domized clinical trials are now urgently needed to This article proposed the Society for Cardiovascular Angiography and Intervention
new classification of cardiogenic shock.
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ces in strategies to treat cardiogenic shock patients. && tion to predict mortality in the cardiac intensive care unit. J Am Coll Cardiol
2019; 74:2117–2128.
This article validated the Society for Cardiovascular Angiography and Intervention
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