Ambulatory simultaneous venoarterial extracorporeal membrane oxygenation and temporary percutaneous left ventricular assist device bridge to heart transplantation

Commentary: Get up and go! Pushing the envelope in ambulatory extracorporeal membrane oxygenation

“…This report from Hess and colleagues 1 is informative to readers and multidisciplinary teams because it illustrates what can be achieved with teamwork and expands the boundaries of what is possible. In time, ambulation with peripheral ECMO may become the rule rather than the exception.…”

“…In this issue of JTCVS Techniques , Hess and colleagues 1 describe the case of a 45-year-old man with nonischemic cardiomyopathy who presented with acute decompensated heart failure and cardiac arrest. The patient was successfully resuscitated, and 12 hours later he was placed on bifemoral venoarterial (VA) extracorporeal membrane oxygenation (ECMO) plus a temporary axillary Impella 5.5 (Abiomed, Danvers, Mass) microaxial left ventricular assist device as a bridge to heart transplant, which was undertaken 13 days later.…”

“… 5 Because different clinical situations (eg, postcardiotomy shock, decompensated heart failure, and acute cardiogenic shock) warrant different strategies, the decision must be individualized to the patient. 6 , 7 The novel approach taken by Hess and colleagues 1 was to initiate peripheral VA-ECMO simultaneously with placement of an Impella 5.5, which the authors expected would provide better cardiac support and be less likely to move or cause hemolysis than alternative devices (eg, femoral Impella CP). Avoiding MCS devices in both femoral arteries may also lower the risk for limb ischemia.…”

“…It is important to appreciate how difficult it is to ambulate patients with femoral cannulation. In the largest reported series of this kind, Pasrija and colleagues 3 were able to ambulate only 14% of patients (15/104) with femoral cannulation, and Hess and colleagues 1 acknowledge that fewer than one half of all patients with femoral VA-ECMO achieved ambulation. Even in the setting of venovenous ECMO for respiratory failure, a large multicenter trial of 511 patients found that 35% of patients were able to be ambulated; however, those with femoral venous cannulation were 5 times less likely to walk, compared with those with alternative (dual-lumen internal jugular or subclavian) cannulation.…”

“…That said, the inertia of stagnation is powerful, and overcoming the “we've never done this before” mindset can be challenging—yet dedicated teams can have a meaningful impact. And sometimes, seeing is believing; for the doubters, Hess and colleagues 1 have included an accompanying video showing the patient safely walking.…”