HERACLES randomized 24 patients receiving VA-ECMO for cardiogenic shock to LV unloading with IABP or a micro-axial flow pump; 96% had SCAI D/E shock. The myocardial oxygen supply-demand ratio improved with IABP but not the micro-axial pump (1.48 [1.23–2.10] versus 0.97 [0.92–1.39]; P=0.036), predominantly reflecting differential reductions in systolic LV pressure burden. LV pressures decreased with both devices, without between-group differences. Thirty-day mortality was 38% versus 45% (P=0.84), leaving uncertain whether the observed mechanistic differences translate into better clinical outcomes.
This small randomized study suggests a mechanistic advantage for IABP in myocardial oxygen supply-demand balance during VA-ECMO. It does not establish superiority in survival or other patient-centred outcomes.
Study limitation: Only 24 patients were enrolled, and the primary endpoint was physiological rather than patient-centred; the mortality comparison cannot establish equivalence.
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