Left ventricular unloading during extracorporeal cardiopulmonary resuscitation: a target trial emulation of the ELSO registry

Ling, RR; Chen, Y; Low, CJW; Agerstrand, C; Jung, JS; Lim, SL; Lorusso, R; Müeller, T; Okada, Y; Tonna, JE; Shekar, K; Brodie, D; MacLaren, G; Ramanathan, K

doi:10.1186/s13054-025-05345-3

Cardiac arrest & resuscitation

Left ventricular unloading during extracorporeal cardiopulmonary resuscitation: a target trial emulation of the Extracorporeal Life Support Organisation (ELSO) registry

Crit CarePublished 8 May 2025Target trial emulation

Main finding · Survival time up to 90 daysResultHR, event not clear (survival time) 0.92 95% CI 0.79–1.08

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Authors' conclusion

Left ventricular unloading was not associated with improved survival in the context of ECPR and may increase complication rates.

Study context

Population: Patients receiving extracorporeal cardiopulmonary resuscitation (ECPR), ELSO registry 2020–2023
Participants: 3,215 patients · 621 matched pairs

Exposure: Concurrent mechanical left ventricular (LV) unloading vs no LV unloading during ECPR
LV unloadingn = 621
No LV unloadingn = 621reference
Outcome: Survival time
Follow-up: Up to 90 days

Methodological detailsretrospective registry cohort study, propensity-score matched, multiple imputation, ELSO registry

Retrospective registry cohort study
Propensity-score matched
Multiple imputation
ELSO registry

Main finding

Survival time up to 90 days

HR, event not clear (survival time)

0.92

95% CI 0.79–1.08

LV unloading vs No LV unloading

HR, event not clear (survival time) 0.92 (95% CI 0.79–1.08)

As reported in the abstract

Observational data: associations, not effects.

Secondary outcomes

Outcome		OR for survival with favourable functional outcome (CPC 1-2) (95% CI)
Survival with favourable functional outcome (CPC 1-2)	0.512	1.15 (0.67–1.99)
	0.512OR for survival with favourable functional outcome (CPC 1-2) (log scale)

Sensitivity analyses

Concordant across several sensitivity analyses

Safety

Outcome	← Lower odds with LV unloading ←→ Higher odds with LV unloading →	OR (95% CI)
Renal complications	0.20.5125	1.55 (1.16–2.07)
Cardiovascular complications	0.20.5125	1.60 (1.14–2.26)
Central nervous system bleeding	0.20.5125	1.75 (1.03–2.96)
Arrhythmias	0.20.5125	1.56 (1.04–2.36)
Haemolysis	0.20.5125	1.85 (1.10–3.09)
	0.20.5125Odds ratio (log scale)

Original publication

Left ventricular unloading during extracorporeal cardiopulmonary resuscitation: a target trial emulation of the ELSO registry. Crit Care. Published 8 May 2025. doi:10.1186/s13054-025-05345-3

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