This study aimed to compare the clinical outcomes of early versus conventional left ventricle (LV) unloading strategies using percutaneous transseptal left atrial cannulation during veno-arterial extracorporeal membrane oxygenation (VA-ECMO) in patients undergoing extracorporeal cardiopulmonary resuscitation (ECPR). We retrospectively reviewed the records of patients who underwent ECPR and LV unloading at a single tertiary referral hospital between July 2013 and May 2024. Early LV unloading was defined as the procedure performed within 12 h of VA-ECMO initiation, while conventional unloading was performed after 12 h. Among 77 patients (mean age, 60.1 years; 56 males), 29 (37.7%) underwent early unloading and 48 (62.3%) underwent conventional unloading (median time to unloading: 2.5 days). The early group had significantly higher 30-day (58.6% vs. 33.3%, p = 0.030) and 1-year (75.9% vs. 52.7%, p = 0.038) mortality rates. Additionally, they had a lower rate of bridging to heart transplantation or LV assist device implantation (10.3% vs. 37.5%, p = 0.010), and a shorter VA-ECMO duration (6.0 days 3.0-9.0 vs. 12.0 days 7.0-23.5, p < 0.001). ECMO-related complications were comparable between groups (67.9% vs. 60.9%, p = 0.625), while poor neurologic outcomes (cerebral performance category ≥ 3) were more frequent in the early group (72.5% vs. 45.8%, p = 0.010). In patients treated with ECPR, early LV unloading was associated with worse survival outcomes and lower rates of transition to definitive therapies. These findings suggest that routine early LV unloading may not be beneficial in this population, and that the timing of unloading should be individualized based on the patient's clinical condition.
Kim et al. (2026) studied this question.