Patients undergoing extracorporeal cardiopulmonary resuscitation (ECPR) frequently require veno-arterial extracorporeal membrane oxygenation (VA-ECMO) to support circulation during refractory cardiac arrest. However, the optimal timing of left ventricular (LV) unloading during ECPR remains uncertain. The optimal timing of LV unloading during ECPR remains uncertain.

A retrospective analysis published in the Artificial Organs reviewed patients who underwent ECPR with LV unloading at a tertiary referral center between July 2013 and May 2024. Early LV unloading was defined as the procedure performed within 12 hours of VA-ECMO initiation, whereas conventional unloading was performed after 12 hours. Clinical outcomes including mortality, bridging to definitive therapies, neurologic outcomes, and ECMO-related complications were compared.

Among 77 patients included in the analysis (mean age 60.1 years; 56 men), 29 (37.7%) underwent early unloading and 48 (62.3%) underwent conventional unloading. Median time to unloading in the conventional group was 2.5 days. The early unloading group demonstrated higher mortality at 30 days (58.6% vs 33.3%, p=0.030) and at 1 year (75.9% vs 52.7%, p=0.038). Early unloading was also associated with lower rates of bridging to heart transplantation or left ventricular assist device implantation (10.3% vs 37.5%, p=0.010). The early group also had 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 similar between groups, while poor neurologic outcomes occurred more frequently in the early unloading group (72.5% vs 45.8%, p=0.010).

Among patients receiving VA-ECMO for ECPR, early LV unloading was associated with lower survival and fewer transitions to definitive therapies. The results suggest that routine early unloading may not improve outcomes and that timing decisions should be guided by individual clinical status.