Letter by Ferreira Regarding Article, “Extracorporeal Membrane Oxygenation in the Therapy of Cardiogenic Shock: Results of the ECMO-CS Randomized Clinical Trial”
2023; Lippincott Williams & Wilkins; Volume: 148; Issue: 9 Linguagem: Inglês
10.1161/circulationaha.122.063622
ISSN1524-4539
Autores Tópico(s)Cardiac Arrest and Resuscitation
ResumoHomeCirculationVol. 148, No. 9Letter by Ferreira Regarding Article, "Extracorporeal Membrane Oxygenation in the Therapy of Cardiogenic Shock: Results of the ECMO-CS Randomized Clinical Trial" Free AccessLetterPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessLetterPDF/EPUBLetter by Ferreira Regarding Article, "Extracorporeal Membrane Oxygenation in the Therapy of Cardiogenic Shock: Results of the ECMO-CS Randomized Clinical Trial" Jorge Ferreira Jorge FerreiraJorge Ferreira https://orcid.org/0000-0002-5592-6199 Cardiology Department, Hospital de Santa Cruz, Centro Hospitalar de Lisboa Ocidental, Carnaxide, Portugal Originally published28 Aug 2023https://doi.org/10.1161/CIRCULATIONAHA.122.063622Circulation. 2023;148:803To the Editor:We read with interest the article by Ostadal et al1 concerning the ECMO-CS randomized clinical trial (Extracorporeal Membrane Oxygenation in Cardiogenic Shock). The study enrolled 122 patients with rapidly deteriorating or severe cardiogenic shock (CS), and immediate implementation of veno-arterial extracorporeal membrane oxygenation (ECMO) did not improve clinical outcomes compared with an early conservative strategy. The authors should be congratulated for performing the first clinical trial of veno-arterial ECMO in this challenging clinical setting.The results of this study are apparently disappointing but must be integrated into the pathophysiology of CS. The classic paradigm is based on cardiac dysfunction and low cardiac output that generates systemic hypoperfusion.2 In this context, it is attractive to consider that mechanical circulatory support can correct the hemodynamic dysfunction, allowing the treatment or stabilization of the underlying heart disease. However, systemic hypoperfusion triggers endothelial dysfunction with inappropriate vasodilation, hemostasis dysregulation, and systemic inflammatory response syndrome that reduce catecholamine responsivity, decrease myocardial contractility, and further depress perfusion pressure.3,4 As a corollary of this new pathophysiologic concept, emergent vasoactive therapy and mechanical circulatory support must be implemented in early phases of CS to prevent triggering of endothelial dysfunction and systemic inflammatory response syndrome.The design of the ECMO-CS trial is apparently in line with this new paradigm because it included a therapeutic strategy of immediate implementation of veno-arterial ECMO in patients with CS.1 However, the study included patients with rapidly deteriorating or severe CS, characterized by ongoing inappropriate endothelial and inflammatory responses. For these patients, new adjunctive therapies targeting endothelial dysfunction and cytokine storm are probably warranted.ARTICLE INFORMATIONDisclosures None.FootnotesCirculation is available at www.ahajournals.org/journal/circReferences1. Ostadal P, Rokyta R, Karasek J, Kruger A, Vondrakova D, Janotka M, Naar J, Smalcova J, Hubatova M, Hromadka M, et al; ECMO-CS Investigators. Extracorporeal membrane oxygenation in the therapy of cardiogenic shock: results of the ECMO-CS randomized clinical trial.Circulation. 2023; 147:454–464. doi: 10.1161/CIRCULATIONAHA.122.062949LinkGoogle Scholar2. Hochman JS. Cardiogenic shock complicating acute myocardial infarction: expanding the paradigm.Circulation. 2003; 107:2998–3002. doi: 10.1161/01.CIR.0000075927.67673.F2LinkGoogle Scholar3. Reynolds HR, Hochman JS. Cardiogenic shock: current concepts and improving outcomes.Circulation. 2008; 117:686–697. doi: 10.1161/CIRCULATIONAHA.106.613596LinkGoogle Scholar4. Ferreira J. Vascular phenotypes of acute decompensated vs. new-onset heart failure: treatment implications.ESC Heart Fail. 2017; 4:679–685. doi: 10.1002/ehf2.12210CrossrefMedlineGoogle Scholar eLetters(0)eLetters should relate to an article recently published in the journal and are not a forum for providing unpublished data. Comments are reviewed for appropriate use of tone and language. Comments are not peer-reviewed. Acceptable comments are posted to the journal website only. Comments are not published in an issue and are not indexed in PubMed. Comments should be no longer than 500 words and will only be posted online. References are limited to 10. Authors of the article cited in the comment will be invited to reply, as appropriate.Comments and feedback on AHA/ASA Scientific Statements and Guidelines should be directed to the AHA/ASA Manuscript Oversight Committee via its Correspondence page.Sign In to Submit a Response to This Article Previous Back to top Next FiguresReferencesRelatedDetails August 29, 2023Vol 148, Issue 9 Advertisement Article InformationMetrics © 2023 American Heart Association, Inc.https://doi.org/10.1161/CIRCULATIONAHA.122.063622PMID: 37639506 Originally publishedAugust 28, 2023 PDF download Advertisement SubjectsAortic Valve Replacement/Transcatheter Aortic Valve ImplantationNuclear Cardiology and PETThrombosisTreatment
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