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      Left ventricular unloading during veno-arterial ECMO: a review of percutaneous and surgical unloading interventions

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          Abstract

          Short-term mechanical support by veno-arterial extracorporeal membrane oxygenation (VA ECMO) is more and more applied in patients with severe cardiogenic shock. A major shortcoming of VA ECMO is its variable, but inherent increase of left ventricular (LV) mechanical load, which may aggravate pulmonary edema and hamper cardiac recovery. In order to mitigate these negative sequelae of VA ECMO, different adjunct LV unloading interventions have gained a broad interest in recent years. Here, we review the whole spectrum of percutaneous and surgical techniques combined with VA ECMO reported to date.

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          Hemodynamics of Mechanical Circulatory Support.

          Daniel Burkhoff, Gabriel Sayer, Darshan Doshi … (2015)
          An increasing number of devices can provide mechanical circulatory support (MCS) to patients with acute hemodynamic compromise and chronic end-stage heart failure. These devices work by different pumping mechanisms, have various flow capacities, are inserted by different techniques, and have different sites from which blood is withdrawn and returned to the body. These factors result in different primary hemodynamic effects and secondary responses of the body. However, these are not generally taken into account when choosing a device for a particular patient or while managing a patient undergoing MCS. In this review, we discuss fundamental principles of cardiac, vascular, and pump mechanics and illustrate how they provide a broad foundation for understanding the complex interactions between the heart, vasculature, and device, and how they may help guide future research to improve patient outcomes.
          Article 0 comments Cited 142 times – based on 0 reviews     Review now
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            Extracorporeal membrane oxygenation in cardiopulmonary disease in adults.

            Darryl Abrams, Alain Combes, Daniel Brodie (2014)
            The use of extracorporeal membrane oxygenation (ECMO) for both respiratory and cardiac failure in adults is evolving rapidly. Advances in technology and accumulating data are spurring greater interest and explosive growth in ECMO worldwide. Expanding indications and novel strategies are being used. Yet the use of ECMO outpaces the data. The promise of a major paradigm shift for the treatment of respiratory and cardiac failure is tempered by a need for evidence to support many current and potential future uses. The authors review cannulation strategies, indications, and evidence for ECMO in respiratory and cardiac failure in adults as well as potential applications and the impact they may have on current treatment paradigms.
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              The Current Use of Impella 2.5 in Acute Myocardial Infarction Complicated by Cardiogenic Shock: Results from the USpella Registry

              William O'Neill, Theodore Schreiber, David Wohns … (2013)
              Objectives To evaluate the periprocedural characteristics and outcomes of patients supported with Impella 2.5 prior to percutaneous coronary intervention (pre-PCI) versus those who received it after PCI (post-PCI) in the setting of cardiogenic shock (CS) complicating an acute myocardial infarction (AMI). Background Early mechanical circulatory support may improve outcome in the setting of CS complicating an AMI. However, the optimal timing to initiate hemodynamic support has not been well characterized. Methods Data from 154 consecutive patients who underwent PCI and Impella 2.5 support from 38 US hospitals participating in the USpella Registry were included in our study. The primary end-point was survival to discharge. Secondary end-points included assessment of patients’ hemodynamics and in-hospital complications. A multivariate regression model was used to identify independent predictors for mortality. Results Both groups were comparable except for diabetes (P = 0.02), peripheral vascular disease (P = 0.008), chronic obstructive pulmonary disease (P = 0.05), and prior stroke (P = 0.04), all of which were more prevalent in the pre-PCI group. Patients in the pre-PCI group had more lesions (P = 0.006) and vessels (P = 0.01) treated. These patients had also significantly better survival to discharge compared to patients in the post-PCI group (65.1% vs.40.7%, P = 0.003). Survival remained favorable for the pre-PCI group after adjusting for potential confounding variables. Initiation of support prior to PCI with Impella 2.5 was an independent predictor of in-hospital survival (Odds ratio 0.37, 95% confidence interval: 0.17–0.79, P = 0.01) in multivariate analysis. The incidence of in-hospital complications included in the secondary end-point was similar between the 2 groups. Conclusions The results of our study suggest that early initiation of hemodynamic support prior to PCI with Impella 2.5 is associated with more complete revascularization and improved survival in the setting of refractory CS complicating an AMI.
              Article 0 comments Cited 90 times – based on 0 reviews     Review now
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                Author and article information

                Journal
                Journal ID (nlm-ta): Perfusion
                Journal ID (iso-abbrev): Perfusion
                Journal ID (publisher-id): PRF
                Journal ID (hwp): spprf
                Title: Perfusion
                Publisher: SAGE Publications (Sage UK: London, England )
                ISSN (Print): 0267-6591
                ISSN (Electronic): 1477-111X
                Publication date (Electronic): 16 August 2018
                Publication date (Print): March 2019
                Volume: 34
                Issue: 2
                Pages: 98-105
                Affiliations
                [1 ]Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
                [2 ]Division of Pulmonary, Allergy and Critical Care Medicine, Columbia University College of Physicians and Surgeons/New York-Presbyterian Hospital, New York, NY, USA
                [3 ]Department of Cardiology, Academic Medical Center, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
                [4 ]ECMO Department, Karolinska University Hospital, Stockholm, Sweden
                [5 ]Anaesthesiology and Intensive Care, Department of Physiology and Pharmacology, Karolinska Institute, Stockholm, Sweden
                [6 ]School of Technology and Health, Royal Institute of Technology, Stockholm, Sweden
                Author notes
                [*]Michael Broomé, ECMO Department, Karolinska University Hospital, Stockholm, SE-171 76, Sweden. Email: michael.broome@ 123456ki.se
                Author information
                https://orcid.org/0000-0001-6496-2768
                https://orcid.org/0000-0002-8987-9909
                Article
                Publisher ID: 10.1177_0267659118794112
                DOI: 10.1177/0267659118794112
                PMC ID: 6378398
                PubMed ID: 30112975
                SO-VID: d1858fd9-693a-4236-abf6-69cc328895a8
                Copyright © © The Author(s) 2018
                License:

                This article is distributed under the terms of the Creative Commons Attribution 4.0 License ( http://www.creativecommons.org/licenses/by/4.0/) which permits any use, reproduction and distribution of the work without further permission provided the original work is attributed as specified on the SAGE and Open Access pages ( https://us.sagepub.com/en-us/nam/open-access-at-sage).

                History
                Funding
                Funded by: Stockholms Läns Landsting, FundRef https://doi.org/10.13039/501100004348;
                Award ID: SLL20160421
                Funded by: Vetenskapsrådet, FundRef https://doi.org/10.13039/501100004359;
                Award ID: 2012-2800
                Categories
                Subject: Review

                Keywords: veno-arterial extracorporeal membrane oxygenation (va ecmo),left ventricular unloading,cardiogenic shock,cardiovascular modeling,computer simulation
                Data availability:
                Keywords: veno-arterial extracorporeal membrane oxygenation (va ecmo), left ventricular unloading, cardiogenic shock, cardiovascular modeling, computer simulation

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