Correspondence

In a study by Uwe Zeymer and in the VA-ECMO-supported pigs than of all-cause death at day 30, now a
colleagues,1 it was observed that for in the control group, and it returned to bedrock of tMCS trials, belies this real-
patients with infarct-related cardiogenic baseline 24 h after the onset of shock.5 world mission statement. Success at
shock, venoarterial extracorporeal To conclude, the efficacy of VA- day 30 depends on either the ability
membrane oxygenation (VA-ECMO) ECMO for patients with infarct-related to reach myocardial recovery (usually
did not reduce the number of all-cause cardiogenic shock still needs further facilitated by coronary reperfusion),
deaths at 30 days compared with evaluation. or candidacy for—and successful
medical treatment alone. Moreover, I declare no competing interests. implementation of—transplantation
there was a marked increase in major or insertion of a durable left ventricular
Yongnan Li
bleeding and vascular complications. [email protected]
assist device (LVAD). VA-ECMO provides
Based on these research findings, a brief first step (only several days in the
Department of Cardiac Surgery, Lanzhou University
the authors concluded that ECMO Second Hospital, Lanzhou University, Lanzhou
trials) towards these options and there
is not universally appropriate for 730030, China are many VA-ECMO independent risks.
every patient, with which we concur. 1 Zeymer U, Freund A, Hochadel M, et al. This endpoint will therefore include
Beyond the patient’s underlying Venoarterial extracorporeal membrane patients who have died from non-
oxygenation in patients with infarct-related
medical condition, the timing of cardiogenic shock: an individual patient data VA-ECMO related issues, including
ECMO deployment plays a pivotal role, meta-analysis of randomised trials. Lancet those with irrecoverable myocardial
2023; 402: 1338–46.
as highlighted by the authors in the injury and concurrent ineligibility for
2 Kagawa E, Dote K, Kato M, et al. Should we
Discussion of their Article.1 Although the emergently revascularize occluded coronaries transplantation or LVAD.
researchers juxtaposed the outcomes of for cardiac arrest?: rapid-response A pragmatic reappraisal of what can
extracorporeal membrane oxygenation and
ECMO administration before and during intra-arrest percutaneous coronary realistically be expected of VA-ECMO
percutaneous coronary intervention intervention. Circulation 2012; 126: 1605–13. in cardiogenic shock is necessary. The
(PCI), we perceive specific shortcomings 3 Tsao N-W, Shih C-M, Yeh J-S, et al. Extracorporeal differences between treatments that
membrane oxygenation-assisted primary
in their methodological approach. percutaneous coronary intervention may independently augment prognosis
Considering that this study is rooted improve survival of patients with acute and prolong life (eg, coronary
myocardial infarction complicated by profound
in an individual patient data meta- cardiogenic shock. J Crit Care 2012; 27: 530. revascularisation, durable LVAD, and
analysis, a more nuanced approach 4 Huang C-C, Hsu J-C, Wu Y-W, et al. transplantation), and opportunity-
would involve pairing patients who Implementation of extracorporeal membrane providing therapies that temporarily
oxygenation before primary percutaneous
underwent ECMO before PCI with their coronary intervention may improve the survival suspend death (eg, tMCS, inotropes,
counterparts who received it during of patients with ST-segment elevation and external defibrillation) need to be
myocardial infarction and refractory cardiogenic
PCI, rather than broadly contrasting shock. Int J Cardiol 2018; 269: 45–50. urgently understood and appreciated.
both patient sets. In a real-world clinical 5 Briceno N, Annamalai SK, Reyelt L, et al. Left Although the former treatments are
setting, those who get ECMO before PCI ventricular unloading increases the coronary routinely judged by all-cause mortality
collateral flow index before reperfusion and
typically need life support, suggesting reduces infarct size in a swine model of acute endpoints, it is unfair and highly
a more severe health state. As such, myocardial infarction. J Am Heart Assoc 2019; dangerous to spuriously tarnish and
8: e013586.
drawing a more definitive conclusion consequently jeopardise the ability
necessitates analysis after aligning these to provide the latter treatments by
patients with those with comparable The meta-analysis by Uwe Zeymer applying the same methods.
conditions who were on ECMO during and colleagues1 deemed venoarterial I declare no competing interests.
PCI. extracorporeal membrane oxygenation
Jonathan R Dalzell
Several studies have shown that (VA-ECMO) an ineffective form of
[email protected]
VA-ECMO implementation before temporary mechanical circulatory
Scottish National Advanced Heart Failure Service,
PCI improves the chance of survival support (tMCS) for myocardial infarc­ Golden Jubilee National Hospital, Glasgow G81 4DY,
in patients with acute myocardial tion-related cardiogenic shock based UK
infarction.2–4 Although the idea of time- on a primary endpoint of all-cause 1 Zeymer U, Freund A, Hochadel M, et al.
to-unload appeared counterintuitive death at day 30. This analysis adds to Venoarterial extracorporeal membrane
oxygenation in patients with infarct-related
in pigs with myocardial infarction the universally neutral studies of tMCS cardiogenic shock: an individual patient data
and cardiogenic shock, it was evident in cardiogenic shock and reinforces an meta-analysis of randomised trials. Lancet
2023; 402: 1338–46.
that initiation of VA-ECMO right uncomfortable discordance between
2 Bernhardt AM, Copeland H, Deswal A, Gluck J,
after shock slowed down the left trial results and international clinical Givertz MM. The International Society for
ventricular end-diastolic pressure practice.2 Heart and Lung Transplantation/Heart Failure
Society of America guideline on acute
(LVEDP) elevation and caused a faster VA-ECMO suspends death to provide mechanical circulatory support.
recovery of pumping function.5 It was an opportunity to access a pathway J Heart Lung Transplant 2023; 42: e1–64.
also found that the LVEDP was lower to survival. However, the endpoint

2486 www.thelancet.com Vol 403 June 8, 2024