ECMO year in review: Veno-Arterial ECLS

A two part review of post-cardiotomy ECMO in adults & pediatrics:
In the adult patients, PC represent PV most frequent indication for temporary MCS; considerable variability about surgical access/cannulation still exists, with no apparent major differences in outcomes. Veno-arterial ECMO can be life-saving, and survivors have favorable early outcomes, but mortality & morbidity remain high, reflecting underlying disease severity and an imperfect solution. When needed, avoid any delay, worsening outcomes as extended duration of hypoperfusion & hypoxia. ECMO-specific educational training programs focusing on patient selection, cannulation techniques, patient management, ethics, along with circuit technology evolution, mandatory to improve effectiveness.

Lorusso R, Raffa GM, Alenizy K, Sluijpers N, Makhoul M, Brodie D, McMullan M, Wang IW, Meani P, MacLaren G, Kowalewski M, Dalton H, Barbaro R, Hou X, Cavarocchi N, Chen YS, Thiagarajan R, Alexander P, Alsoufi B, Bermudez CA, Shah AS, Haft J, D’Alessandro DA, Boeken U, Whitman GJR. Structured review of post-cardiotomy extracorporeal membrane oxygenation: part 1-Adult patients. J Heart Lung Transplant. 2019 Nov;38(11):1125-1143. link

In pediatric patients represents an optimal support technique in CHD & post-cardiotomy shock, optimizing pre/postop metabolic status, and potentially improving survival of this high risk population, even if mortality/morbidity remain high. Neuro-injury & neurodevelopmental impairment are common post ECLS, reflecting severity of illness, complexity of cardiac surgery, ECMO complications. If no recovery, bridge to cardiac Tx can be successful, but organs availability/waiting list duration impact on survival.

Lorusso R, Raffa GM, Kowalewski M, Alenizy K, Sluijpers N, Makhoul M, Brodie D, McMullan M, Wang IW, Meani P, MacLaren G, Dalton H, Barbaro R1, Hou X, Cavarocchi N, Chen YS, Thiagarajan R, Alexander P, Alsoufi B, Bermudez CA, Shah AS, Haft J, Oreto L, D’Alessandro DA, Boeken U, Whitman G. Structured review of post-cardiotomy extracorporeal membrane oxygenation: Part 2-pediatric patients. J Heart Lung Transplant. 2019 Nov;38(11):1144-1161. link

Cardiac ECMO in neonates: invaluable tool to support therapy resistant circulatory failure; patient selection & timing for implementing ECLS remain very difficult and not yet evidence based. Mortality is very much dependent on underlying diagnosis, the ability to provide adequate systemic blood flow, duration of ECMO run, adverse events and complications: therefore, after initiation, attempts should be made to early identify and address concomitant conditions as residual lesions following cardiac surgery or arrhythmias, and to limit ECLS duration, resting the heart as much as possible, to reduce mortality. In this interesting and complete review, timing & indications for ECMO support in congenital heart disease, myocarditis/cardiomyopathy, arrhythmias, PH; contraindications, cannulation & neonatal extracorporeal circuit considerations, supportive care, #ultrasound and mechanical ventilation, predictors of survival, weaning, mid/long term outcomes (neuro-developmental) outcomes, future & research.

Roeleveld PP, Mendonca M. Neonatal Cardiac ECMO in 2019 and Beyond. Front Pediatr. 2019 Aug 21;7:327. Open access link

MCS & cardiogenic shock: initial assessment, optimization & stabilization, titrating therapies, specific management according to the etiology, veno-arterial ECMO and other mechanical circulatory supports, role of a MCS team, future perspectives.

Hajjar LA, Teboul JL. Mechanical Circulatory Support Devices for Cardiogenic Shock: State of the Art. Crit Care. 2019 Mar 9;23(1):76. Open access link

VA ECMO, allowing rapid improvement in oxygenation, suitable in severe biventricular failure, and less expensive compared with other devices, has emerged as the first-line temporary circulatory support to manage patients with severe or refractory cardiogenic shock. In this review, VA ECLS principles, growing and emerging accepted indications, mode of operation, patient management, complications, with a discussion about current evidence: results of recent case series & trials.

Pineton de Chambrun M, Bréchot N, Combes A. Venoarterial extracorporeal membrane oxygenation in cardiogenic shock: indications, mode of operation, and current evidence. Curr Opin Crit Care. 2019 Aug;25(4):397-402. link

Veno-arterial ECMO support in severe or refractory cardiogenic shock, http://bit.ly/2xe3W7d

Despite technological advancements & improvements in ECMO devices, allowing for a better risk/benefit profile, extracorporeal support remains an invasive procedure associated with potentially severe complications that could strongly impact on outcome: this open access review provides a comprehensive outline on veno-arterial ECLS complications in adult patients, analyzing risk factors and strategies of management.

Lo Coco V, Lorusso R, Raffa GM, Malvindi PG, Pilato M, Martucci G, Arcadipane A, Zieliński K, Suwalski P, Kowalewski M. Clinical complications during veno-arterial extracorporeal membrane oxigenation in post-cardiotomy and non post-cardiotomy shock: still the achille’s heel. J Thorac Dis. 2018 Dec;10(12):6993-7004. link

VA ECMO for CS: an introduction for the busy clinician…epidemiology of cardiogenic shock & extracorporeal supportIndications/contraindications and short-term outcomes by indication, circuit & cannulation management & main complications, left heart venting, prognosis and weaning, conversion to durable MCS/heart Tx option, or withdrawal of support, models of care for patients on ECLS, futility, ethics and cost considerations.

Eckman PM, Katz JN, El Banayosy A, Bohula EA, Sun B, van Diepen S. Veno-Arterial Extracorporeal Membrane Oxygenation for Cardiogenic Shock: An Introduction for the Busy Clinician. Circulation. 2019 Dec 10;140(24):2019-2037. Open access link

Predicting (& trying to improve) outcome

Scores for veno-arterial ECMO patients could help at bedside by providing information on outcome prediction as well as be of interest for research purposes; should they be used be used as a decision tool to indicate or limit access to ECLS? Never, according to this editorial.

Kimmoun A, Levy B. Predicting clinical outcome in patients undergoing VA-ECMO. Crit Care. 2019 Feb 14;23(1):47. Open access link

PS here links to the original papers presenting the cited scores:
SAVE-score, Schmidt et al. 2015, for refractory cardiogenic shock open access link

ENCOURAGE score, Muller et al. 2016, for acute myocardial infarction with CS link

REMEMBER to predict in-hospital mortality for patients receiving veno-arterial #ECMO for cardiogenic shock after isolated CABG: proposal of a new score, appearing better than others for the selected population, in this study identifying four risk classes with their corresponding mortality (13%, 55%, 70%, and 94%, respectively).

Wang L, Yang F, Wang X, Xie H, Fan E, Ogino M, Brodie D, Wang H, Hou X. Predicting mortality in patients undergoing VA-ECMO after coronary artery bypass grafting: the REMEMBER score. Crit Care. 2019 Jan 11;23(1):11. Open access link

May regional cerebral oxygen saturation be used as a monitoring parameter for mortality in patients on VA ECMO support? this retrospective study reports higher rScO2 values & lower lactate levels in the survivor vs nonsurvivor group during the first 7 days; the risks of 28 day mortality seems higher among patients with a right rScO2 of <58% and a left rScO2 of <57%.

Kim HS, Ha SO, Yu KH, Oh MS, Park S, Lee SH, Han SJ, Kim HS, Chang IB, Ahn JH. Cerebral Oxygenation as a Monitoring Parameter for Mortality During Venoarterial Extracorporeal Membrane Oxygenation. ASAIO J. 2019 May/Jun;65(4):342-348. link

Association of early fibrinogen/albumin ratio & ischemic stroke on veno-arterial ECMO support: according to this single center, retrospective study on adult patients, the level of FAR seems associated with an incrementally higher likelihood of subsequent ischemic stroke. May FAR evaluation, calculated in the first 24 hours, assist with early stratification of patients at risk for development of ischemic neurologic complications on ECLS?

Acharya P, Jakobleff WA, Forest SJ, Chinnadurai T, Mellas N, Patel SR, Kizer JR, Billett HH, Goldstein DJ, Jorde UP, Saeed O. Fibrinogen Albumin Ratio and Ischemic Stroke During Venoarterial Extracorporeal Membrane Oxygenation. ASAIO J. 2019 Mar 27. link

Development of the PEP Pediatric ECMO Prediction model for predicting in-hospital mortality among children receiving ECLS for any indication.

Bailly DK, Reeder RW, Winder M, Barbaro RP, Pollack MM, Moler FW, Meert KL, Berg RA, Carcillo J, Zuppa AF, Newth C, Berger J, Bell MJ, Dean MJ, Nicholson C, Garcia-Filion P, Wessel D, Heidemann S, Doctor A, Harrison R, Bratton SL, Dalton H; Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) Collaborative Pediatric Critical Care Research Network (CPCCRN).Development of the Pediatric Extracorporeal Membrane Oxygenation Prediction Model for Risk-Adjusting Mortality. Pediatr Crit Care Med. 2019 May;20(5):426-434. link

… with related editorial: MacLaren G, Cho HJ, Schlapbach LJ. Transforming Data Into a Crystal Ball-Predicting Outcomes After Extracorporeal Membrane Oxygenation. Pediatr Crit Care Med. 2019 May;20(5):490-491. link

Calculator available at link

It is unlikely that low-volume centers will be efficient or facile in managing complex ECLS cases. How to achieve greater efficiency improving outcomes? developing regional networks and consolidating cooperation to share costs & direct resources to centers with better outcomes. Fast, early cannulation (as lactates at time of ECMO implementation is a strong predictor of mortality) at smaller hospitals by outside physicians, with transfer to an experienced ECMO referral center, could be an effective approach to increase survival in cardiogenic shock. These patients can be safely transported on extracorporeal support, as long as the transfer team is well experienced. Alternatively, mobile VA ECMO teams could be developed, based out of the ECMO referral center.

Mazzeffi M, Del Rio JM, Gutsche J. Give Me Your Tired, Your Poor, Your Extracorporeal Membrane Oxygenation Patients. J Cardiothorac Vasc Anesth. 2019 Nov;33(11):3054-3055. Open access editorial link

And its related paper: an high-volume single-center large experience with veno-arterial ECMO, comparing outcomes for patients cannulated in-house vs those transferred from a referral hospital after cannulation, reporting no difference in survival to ECLS or to discharge.

Dalia AA, Axtel A, Villavicencio M, D’Allesandro D, Shelton K, Cudemus G, Ortoleva J. A 266 Patient Experience of a Quaternary Care Referral Center for Extracorporeal Membrane Oxygenation with Assessment of Outcomes for Transferred Versus In-House Patients. J Cardiothorac Vasc Anesth. 2019 Nov;33(11):3048-3053. link

ECMO? Is a team Sport!! The implementation of a multidisciplinary ECLS team establishing a set of protocols & guidelines to care for patients on extracorporeal support played an integral role in the improvement in survival to discharge at the authors’ institution.

Dalia AA, Ortoleva J, Fiedler A, Villavicencio M, Shelton K, Cudemus GD. Extracorporeal Membrane Oxygenation Is a Team Sport: Institutional Survival Benefits of a Formalized ECMO Team. J Cardiothorac Vasc Anesth. 2019 Apr;33(4):902-907. link

Early vs delayed ECMO support in cardiogenic failure refractory to medical management for cardiovascular surgery patients? the implementation of an aggressive strategy, early initiating post-cardiotomy extracorporeal support, lead to increased survival in this single center experience, improving cardiac output, promoting lactate clearance, decreasing complications and shortening ECLS run, MV time & ICU stay.

Ge M, Pan T, Wang JX, Chen ZJ, Wang DJ. Outcomes of early versus delayed initiation of extracorporeal life support in cardiac surgery. J Cardiothorac Surg. 2019 Jul 4;14(1):129. Open access link

Mortality & risk profiles in infants with CDH supported with ECMO over the years: although the overall mortality rate near 50% remained approximately constant over time, individual likelihood of death has declined over time in the moderate-risk cohort, remained unchanged in the high-risk cohort, increased in the low-risk cohort. About last group, there was a decreasing frequency of low-risk infants placed on ECMO in later years but with an increasing mortality risk profile among those who were cannulated.

Guner YS, Delaplain PT, Zhang L, Di Nardo M, Brogan TV, Chen Y, Cleary JP, Yu PT, Harting MT, Ford HR, Nguyen DV. Trends in Mortality and Risk Characteristics of Congenital Diaphragmatic Hernia Treated With Extracorporeal Membrane Oxygenation. ASAIO J. 2019 Jul;65(5):509-515. Open access link

PS also check this (2018) paper about the development & validation of ECMO mortality-risk models for Congenital Diaphragmatic Hernia.

Guner YS, Nguyen DV, Zhang L, Chen Y, Harting MT, Rycus P, Barbaro R, Di Nardo M, Brogan TV, Cleary JP, Yu PT. Development and Validation of Extracorporeal Membrane Oxygenation Mortality-Risk Models for Congenital Diaphragmatic Hernia. ASAIO J. 2018 Nov/Dec;64(6):785-794. Open access link

here the online calculators for both pre/on-#ECLS mortality-risk models for CDH, freely accessible link

Hyperlactatemia as readily available, valid biomarker indicating very poor tissue perfusion on veno-arterial ECMO (due to inappropriate extracorporeal blood flow or peripheral conditions or local obstruction), facilitating prediction of early outcome & improving prognosis these critically ills, a comment.

Formica F, D’Alessandro S, Sangalli F. Arterial lactate level. A simple and effective tool during extracorporeal membrane oxygenation. J Thorac Cardiovasc Surg. 2019 May;157(5):e265-e266. link

referring to this (2018) study: Fux T, Holm M, Corbascio M, Lund LH, van der Linden J. Venoarterial extracorporeal membrane oxygenation for postcardiotomy shock: Risk factors for mortality. J Thorac Cardiovasc Surg. 2018 Nov;156(5):1894-1902.e3. link
… & take a look at this open access cited (2010) paper too! Formica F, Avalli L, Colagrande L, Ferro O, Greco G, Maggioni E, Paolini G. Extracorporeal membrane oxygenation to support adult patients with cardiac failure: predictive factors of 30-day mortality. Interact Cardiovasc Thorac Surg. 2010 May;10(5):721-6. link

Epinephrine, inodilator, or no inotrope on VA ECMO?? after cannulation, vasoplegia & cardiac depression are frequent; in this large single-center experience, patients on continuous epinephrine infusion within the first day of ECLS performed significantly worse compared to patients with or without inodilator therapy.

Zotzmann V, Rilinger J, Lang CN, Kaier K, Benk C, Duerschmied D, Biever PM, Bode C, Wengenmayer T, Staudacher DL. Epinephrine, inodilator, or no inotrope in venoarterial extracorporeal membrane oxygenation implantation: a single-center experience. Crit Care 23, 320 (2019). Open access link

Pediatric ECLS, an integral part of modern PedsICU care, rapidly growing world-wide… even if still associated costly/complex, and potentially associated to severe complications. What’s new and what the priorities for both mechanical circulatory/respiratory support? patient selection and timing, extracorporeal cardiopulmonary resuscitation ECPR, longterm neurodevelopmental outcomes and volume–outcome relationships, anticoagulation management prevention/rescue from bleeding & thrombotic complications. Read this experts’ opinion…

MacLaren G, Brown KL, Thiagarajan RR. What’s new in paediatric extracorporeal life support? Intensive Care Med. 2019 Nov 25. link

Hemodynamics & hemodynamic monitoring

Hemodynamics on Veno-Arterial ECMO for Cardiac Support, an international (worldwide) survey among ELSO Centers, collecting data related to the center characteristics and hemodynamic goals & management strategies (echomonitoring & echocardiographic parameters at weaning, LV venting, pulsatility, inotropes, fluid balance) to identify which areas could provide further investigation in a hypothesis-generating manner. PS also check the supplemental pics with interesting data related to geographical differences in approaching the patient ie echomonitoring (timing/parameters) LV venting strategies, weaning…

Siriwardena M, Dozois M, Fan E, Billia F. Hemodynamic Aspects of Veno-Arterial Extracorporeal Membrane Oxygenation for Cardiac Support: A Worldwide Survey. ASAIO J. 2019 Jun 5. link

Challenging case presented in this report, highlighting diagnostic dilemmas of cardiac tamponade on veno-arterial ECMO support & potential effects of drainage pressure.

Adams AJ, Guck AN, Shillcutt SK. Right Atrial Inversion Mimicking Right Atrial Mass in the Setting of Cardiac Tamponade. J Cardiothorac Vasc Anesth. 2019 Aug;33(8):2351-2355. link

… with some considerations about echocardiography & ECLS in the related open access editorial

Gutsche JT, Ortoleva J. Echocardiography: Do We Need New Standards for ECMO Patients? J Cardiothorac Vasc Anesth. 2019 Aug;33(8):2356-2357. link

Markedly collapsed right atrium on veno-arterial ECMO with drainage cannula at RA/IVC junction: is this echo finding a consistent early ( = before lowering of drainage pressure, chattering, flow drop) sign of (even small degree) hypovolaemia?

Au SY, Fong KM, Wu HLH, Ng WYG. Collapsed right atrium as an early sign of hypovolemia in VA ECMO. J Echocardiogr. 2019 Mar 27. link

Hemodynamic monitoring in the ECMO patient, a review: understanding the unique physiology of extracorporeal support is mandatory; multiple threats to perfusion due to ECLS induced circulation perturbations, and not so easy to judge perfusion adequacy as validity of many monitoring tools impaired on extracorporeal support; POCUS and NIRS can play a significant role in monitoring adequacy of global/regional perfusion; consider checking LV overload/distention, RV failure, cannula malposition & cannulated limb ischemia.

Krishnan S, Schmidt GA. Hemodynamic monitoring in the extracorporeal membrane oxygenation patient. Curr Opin Crit Care. 2019 Jun;25(3):285-291. link

Microcirculation monitoring: promising tool to be integrated in clinical practice, to predict outcome/guide treatments of patients with refractory cardiogenic shock requiring veno-arterial ECMO support? in this prospective study, authors report severely impaired microcirculation parameters in this population; furthermore, inability to early/quickly normalize microcirculation in the first 24 hours, despite normal global/macrocirculatory hemodynamics, was associated with increased risk of death on ECLS.

Chommeloux J, Montero S, Franchineau G, Bréchot N, Hékimian G, Lebreton G, Le Guennec L, Bourcier S, Nieszkowska A, Leprince P, Luyt CE, Combes A, Schmidt M. Microcirculation Evolution in Patients on Venoarterial Extracorporeal Membrane Oxygenation for Refractory Cardiogenic Shock. Crit Care Med. 2020 Jan;48(1):e9-e17. link

Intracardiac (not only) thrombosis & SEC on ECMO support

SEC or thrombus?? Spontaneous echo contrast is an echogenic swirling pattern of blood as flow velocity is markedly decreased, and could result in increased risk of intracardiac thrombus & stroke; take a look at these TEE transesophageal echo images of a patient on ECMO support: here, SEC mimics a thrombotic lesion in the aortic root.

De Bono JA, McGiffin DC, Waldron BJF, Leet AS, Doi A.Spontaneous echo contrast mimicking aortic root thrombus in a patient supported with extracorporeal membrane oxygenation. Echocardiography. 2019 Feb;36(2):419-421. link

A case of massive pulmonary embolism evolved in sudden right sided intra-cardiac thrombosis while being optimally anticoagulated on veno-arterial ECMO and related review of the literature describing pathophysiology, risk stratification, prevention, & management of this rare entity.

Bhat AG, Golchin A, Pasupula DK, Hernandez-Montfort JA. Right Sided Intracardiac Thrombosis during Veno-Arterial Extracorporeal Membrane Oxygenation: A Case Report and Literature Review. Case Rep Crit Care. 2019 Jan 6;2019:8594681. Open access link

Prosthetic valves and veno-arterial ECMO?? maintain a high index of clinical suspicion for potential thrombosis & reassess valvular function to early detect, decompressing the left ventricle and allowing valves to open/close to avoid stasis, carefully managing anticoagulation; eventually consider reconfiguration if indicated. Here, a couple of cases of this “unfriendly” combination…

bioprosthetic mitral valve thrombosis on extracorporeal support:
Dahl AB, Gregory SH, Ursprung E, Kawabori M, Couper GS, Hueneke R. Acute Presentation of Bioprosthetic Mitral Valve Thrombosis in a Patient on Venoarterial Extracorporeal Membranous Oxygenation. J Cardiothorac Vasc Anesth. 2019 Mar;33(3):844-849. link

… and mechanical mitral valve thrombosis on ECLS: Sandoval E, Ascaso M, Pereda D, Quintana E. Extracorporeal membrane oxygenation and mechanical valves: An unfriendly relationship. J Thorac Cardiovasc Surg. 2018 Aug;156(2):e103-e105. link

Spontaneous echo-contrast in the aortic root in a pt on veno-arterial support & severe LV hypokinesis + no AV opening pattern despite inotropes/IABP: try to maintain pulsatility to avoid thrombosis. Dilemma: is a thrombus already there? look for evidence of reversibility of SEC. A case rep with nice scans.

Duncan K, Thorleifson M, Ghorpade N, Grocott H. A Concerning Finding in the Aortic Root of a Patient on Venoarterial Extracorporeal Membrane Oxygenation. J Cardiothorac Vasc Anesth. 2019 Dec;33(12):3517-3518. link

Acute coronary syndrome on veno-arterial ECMO? take a look at aortic valve… is it opening or not?? open access case rep about complication of blood stasis on VA ECLS with TEE scans.

Au S, Fong K, Yuen HJ, Shek KJ, Ng WG. A special cause of acute coronary syndrome in patients supported with VA ECMO. J Emerg Crit Care Med 2019;3:58 link

Left (& right) ventricular distention and unload

Reviewing the pathophysiology underlying Left Ventricular distension on veno-arterial ECMO & constructing a systematic diagnostic and therapeutic approach: if IABP or direct left vent already in place at the time of ECLS initiation, these should be continued; as this severe complication occurs, treatment is required. However, whether venting should be performed prophylactically versus selectively in high risk patients, or only post hoc to treat distension, remains unclear.

Rajagopal K. Left Ventricular Distension in Veno-arterial Extracorporeal Membrane Oxygenation: From Mechanics to Therapies. ASAIO J. 2019 Jan;65(1):1-10. link

Unloading LV on veno-arterial ECMO, narrative review: implications of left ventricular distension, monitoring cardiac ejection & echocardiographic detection of LV distention/assessment of decompression, spontaneous echo contrast, aortic regurgitation, identifying patients with minimal or no ejection during ECLS, who may benefit from left ventricular decompression strategies. Managing extracorporeal blood flow, mean arterial pressure, differential hypoxemia, pharmacological approach to ventricular dysfunction; IABP, atrial septostomy & percutaneous right & left ventricular assist devices. An early evaluation of cardiac, neurological, systemic recovery is recommended, with eventual switch to percutaneous LVAD &/or RVAD, decision regarding transplantation, or long term ventricular assist device implantation for destination therapy. http://bit.ly/2MEi83f

Desai SR, Hwang NC. Strategies for Left Ventricular Decompression During Venoarterial Extracorporeal Membrane Oxygenation – A Narrative Review. J Cardiothorac Vasc Anesth. 2020 Jan;34(1):208-218. link

Approaches & timing of left ventricular venting on central and peripheral VA ECLS in cardiogenic shock: a systematic review with one of the largest meta-analysis (to date). Authors report more successful weaning & lower 30-day mortality among patients who received concomitant LV venting; moreover, early (within 12 hours) initiation of LV venting seems associated with better outcomes; a nonsignificant trend towards improved in-hospital and long-term mortality has been observed.

Al-Fares AA, Randhawa VK, Englesakis M, McDonald MA, Nagpal AD, Estep JD, Soltesz EG, Fan E. Optimal Strategy and Timing of Left Ventricular Venting During Veno-Arterial Extracorporeal Life Support for Adults in Cardiogenic Shock: A Systematic Review and Meta-Analysis. Circ Heart Fail. 2019 Nov;12(11):e006486. link

and the related editorial highlighting that veno-arterial ECMO may provide circulatory support but requires concomitant strategies to provide cardiac support & to protect LV from injury mediated by (ECMO) increased afterload, and advocating more data to improve risk prediction and MCS management in cardiogenic shock.

Kapur NK, Davila CD, Chweich H. Protecting the Vulnerable Left Ventricle: The Art of Unloading With VA-ECMO. Circ Heart Fail. 2019 Nov;12(11):e006581. link

Left Ventricular unloading during VA ECMO support in adult patients with cardiogenic shock, a meta-analysis examining the efficacy & safety of unloading strategies in adult patients with cardiogenic shock on veno-arterial ECLS: unloading on ECLS is associated with decreased mortality in observational studies; in the absence of prospective randomized data, may be considered for selected patients.

Russo JJ, Aleksova N, Pitcher I, Couture E, Parlow S, Faraz M, Visintini S, Simard T, Di Santo P, Mathew R, So DY, Takeda K, Garan AR, Karmpaliotis D, Takayama H, Kirtane AJ, Hibbert B. Left Ventricular Unloading During Extracorporeal Membrane Oxygenation in Patients With Cardiogenic Shock. J Am Coll Cardiol. 2019 Feb 19;73(6):654-662. Open access link

And here a couple of comments
Meuwese CL, Koudstaal S, Braithwaite S, Hermens JAJ, Donker DW. Left Ventricular Unloading During Extracorporeal Membrane Oxygenation: Insights From Meta-Analyzed Observational Data Corrected for Confounders. J Am Coll Cardiol. 2019 Jun 18;73(23):3034-3035. link
Li Y, Gao S, Cai L, Zhang Q. Left Ventricle Unloading Strategy: Which One Is More Effective in Venoarterial Extracorporeal Membrane Oxygenation Patients? J Am Coll Cardiol. 2019 Jun 18;73(23):3035-3036. link

and the authors’ reply
Russo JJ, Di Santo P, Kirtane AJ, Hibbert B. Reply: Left Ventricle Unloading Strategy: Which One Is More Effective in Venoarterial Extracorporeal Membrane Oxygenation Patients? J Am Coll Cardiol. 2019 Jun. link 18;73(23):3036.

Consequences of failing to prevent, diagnose, & treat LV distension on VA ECMO are severe, and may worsen left ventricular function, impairing cardiac recovery, contributing to blood stasis and LV/aortic root thrombus formation, worsening pulmonary edema. Physiologic basis and clinical manifestations of left ventricular distension on veno-arterial ECMO support, indications for venting, management strategies, a review.

Cevasco M, Takayama H, Ando M, Garan AR, Naka Y, Takeda K. Left ventricular distension and venting strategies for patients on venoarterial extracorporeal membrane oxygenation. J Thorac Dis. 2019 Apr;11(4):1676-1683. Open access link

ECMO + IABP?? a study examining the effect of the simultaneous use of IABP during ECLS with central cannulation, providing insights into IABP-mediated LV unloading: Intra-Aortic Balloon Pump has the ability to reduce pulmonary artery pressure in these patients; however, this did not translate into improved survival or clinical outcomes.

Tepper S, Garcia MB, Fischer I, Ahmed A, Khan A, Balsara KR, Masood MF, Itoh A. Clinical Outcomes and Reduced Pulmonary Artery Pressure With Intra-Aortic Balloon Pump During Central Extracorporeal Life Support. ASAIO J. 2019 Feb;65(2):173-179. link

Timing & approach for left atrial decompression on VA ECLS: in this multicenter study on a large cohort of pediatric patients receiving venoarterial #ECMO, late (≥ 18 hr) LA unload associated with longer duration of run & mechanical ventilation; authors suggest, taking into account complications associated with prolonged extracorporeal support, this may justify a recommendation for early decompression, even if no survival benefit demonstrated.

Zampi JD, Alghanem F, Yu S, Callahan R, Curzon CL, Delaney JW, Gray RG, Herbert CE, Leahy RA, Lowery R, Pasquali SK, Patel PM, Porras D, Shahanavaz S, Thiagarajan RR, Trucco SM, Turner ME, Veeram Reddy SR, West SC, Whiteside W, Goldstein BH. Relationship Between Time to Left Atrial Decompression and Outcomes in Patients Receiving Venoarterial Extracorporeal Membrane Oxygenation Support: A Multicenter Pediatric Interventional Cardiology Early-Career Society Study. Pediatr Crit Care Med. 2019 Aug;20(8):728-736. link

… here related editorial Coleman RD, Chartan C, Qureshi AM, Shekerdemian LS. Left Atrial Decompression on Venoarterial Extracorporeal Membrane Oxygenation: Getting to the Heart of the Matter.Pediatr Crit Care Med. 2019 Aug;20(8):780-781. link

ECPELLA? concomitant Impella device in patients on venoarterial extracorporeal support: an increasingly applied strategy to manage patients with cardiogenic shock requiring VA ECMO, according to the results of this review. Use of the LVAD seems associated with higher weaning from ECLS in most of the included studies. In the two (over 5) studies adjusting for potential confounders (baseline characteristics between groups) 30 day mortality reported as lower in the ECPELLA group versus VA ECMO alone.

Vallabhajosyula S, O’Horo JC, Antharam P, Ananthaneni S, Vallabhajosyula S, Stulak JM, Dunlay SM, Holmes DR Jr, Barsness GW1. Venoarterial Extracorporeal Membrane Oxygenation With Concomitant Impella Versus Venoarterial Extracorporeal Membrane Oxygenation for Cardiogenic Shock. ASAIO J. 2019 Jul 17. link

ECMO support and Impella ventricular unload… be aware of the lot of potential interactions and regularly check with #ultrasound to early detect eventual complications, displacement or hemodynamic effects of extracorporeal blood & LVAD flows adjustment during the run, a case rep with interesting pics/video of POCUS scans.

Au SY, Fong KM, Ng WYG, So SO, Leung KHA. Interaction between VA-ECMO and Impella. J Echocardiogr. 2019 Oct 11. link

Percutaneous cannula insertion through IJV on peripheral veno-arterial ECMO to reach & vent main PA, allowing additional RV drainage & satisfactory LV unloading, to manage ECLS with biventricular dysfunction.

Loforte A, Baiocchi M, Dal Checco E, Gliozzi G, Fiorentino M, Lo Coco V, Martin Suarez S, Marrozzini C, Biffi M, Marinelli G, Pacini D. Percutaneous Pulmonary Artery Venting via Jugular Vein While on Peripheral Extracorporeal Life Support. ASAIO J. 2019 Mar 19. Open access link

Time to LA decompression & outcomes on VA ECMO: in this multicenter study on pediatrics, late LA decompression (≥ 18hr) associated with longer duration of ECLS, mechanical ventilation, ICU stay, independently of severity of illness & comorbidities; although no survival benefit noticed, authors suggest that earlier left atrial unload may be beneficial.

Zampi JD, Alghanem F, Yu S, Callahan R, Curzon CL, Delaney JW, Gray RG, Herbert CE, Leahy RA, Lowery R, Pasquali SK, Patel PM, Porras D, Shahanavaz S, Thiagarajan RR, Trucco SM, Turner ME, Veeram Reddy SR, West SC, Whiteside W, Goldstein BH. Relationship Between Time to Left Atrial Decompression and Outcomes in Patients Receiving Venoarterial Extracorporeal Membrane Oxygenation Support: A Multicenter Pediatric Interventional Cardiology Early-Career Society Study. Pediatr Crit Care Med. 2019 Aug;20(8):728-736. link

A case demonstrating the hemodynamics of a “trapped ventricle” in a patient on extracorporeal CPR ECPR with profound ventricular dysfunction: despite the end-organ perfusion benefits associated with ECMO support, the increased afterload calls for LV unloading to allow for cardiac recovery, take a look at the videos/pictures in this paper!

Alam A, Mody K, Iyer D, Ikegami H, Hakeem A. “The Trapped Ventricle”: Importance of Left Ventricular Unloading in Resuscitated Patients on VA-ECMO. JACC Cardiovasc Interv. 2019 Feb 25;12(4):e33-e34. link

other complications of (or on) veno-arterial ECMO

Differential Hypoxemia: part of the physiology of veno-arterial ECMO support… in this open access paper from the Karolinska Hospital ECMO Center: O2 delivery on ECLS, physiology, assessment & management of fulminant DH & proposal of a solution, to drain venous blood from SVC, appearing superior vs veno-arterovenous configuration in terms of rationale, efficiency, safety, & simplicity in clinical circuit design.

Falk L, Sallisalmi M, Lindholm JA, Lindfors M, Frenckner B, Broomé M, Broman LM. Differential hypoxemia during venoarterial extracorporeal membrane oxygenation. Perfusion. 2019 Apr;34(1_suppl):22-29. Open access link

Successful mechanical thrombectomy in acute ischemic stroke occurring on veno-arterial ECMO support, report of two adult cases with good long term neuro-outcome; in both cases, femoral access opposite to the arterial return cannula has been chosen to perform the procedure, even if authors suggest eventually to consider transradial access ie if IABP in use (avoiding ipsilateral radial artery if axillary ECLS outflow cannula). All arterial accesses can be considered in veno-arterial ECMO configuration.

Le Guennec L, Schmidt M, Clarençon F, Elhfnawy AM, Baronnet F, Kalamarides M, Lebreton G, Luyt CE. Mechanical thrombectomy in acute ischemic stroke patients under venoarterial extracorporeal membrane oxygenation. J Neurointerv Surg. 2019 Nov 19. link

Shunt of bacterial vegetation from tricuspid valve to aorta in a pt on veno-arterial ECMO support + Impella (ECPELLA or ECMELLA) with no intra-cardiac shunt & no lesions on other valves, likely drained from right & returned to left from ECLS.

Au SY, Fong KM, Ng GWY, So SO. Vegetation shunted from right to left by VA-ECMO. Intensive Care Med. 2019 Oct;45(10):1474-1475. link

Veno-arterial ECMO support as successfull bridge to recovery in pericardial decompression syndrome: report of a case & discussion about potential pathophysiology mechanisms of PDS, a rare & still to be fully understood dysfunction, occurring immediately or early after pericardial drainage, associated with very high morbidity and mortality rates. MCS could be considered as full & rapid recovery is possible.

Ricarte Bratti JP, Brunette V, Lebon JS, Pellerin M, Lamarche Y. Venoarterial Extracorporeal Membrane Oxygenation Support for Severe Pericardial Decompression Syndrome: A Case Report. Crit Care Med. 2020 Jan;48(1):e74-e75. link

PS about ECPR check the dedicated section! link

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