Controversies in extracorporeal membrane oxygenation: Immediate versus watchful waiting for venoarterial extracorporeal membrane oxygenation venting

Cavayas, Yiorgos Alexandros; Noly, Pierre‐Emmanuel; Singh, Gurmeet; Lamarche, Yoan

doi:10.1016/j.xjon.2021.10.008

Cited by 7 publications

(5 citation statements)

References 31 publications

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“…The decision of whether to use LV unloading and the choice of device should be guided by use of a pulmonary artery catheter to assess hemodynamics and achieve near normal filling pressures with minimal vasopressor or inotrope use, thus tailoring it to each individual patient through a nuanced decision‐making process. Certain subsets of patients on VA‐ECMO, such as those without pulsatility following initiation of support, those with pulmonary edema at the time of VA‐ECMO cannulation, or those with significant left side valve regurgitation, 17 would benefit from direct LV venting using Impella to avert complications such as worsening pulmonary edema or LV thrombosis. 17 , 18 Therefore, more detailed short‐term results need to be analyzed on VA‐ECMO with Impella.…”

Section: Discussionmentioning

confidence: 99%

“…Certain subsets of patients on VA‐ECMO, such as those without pulsatility following initiation of support, those with pulmonary edema at the time of VA‐ECMO cannulation, or those with significant left side valve regurgitation, 17 would benefit from direct LV venting using Impella to avert complications such as worsening pulmonary edema or LV thrombosis. 17 , 18 Therefore, more detailed short‐term results need to be analyzed on VA‐ECMO with Impella. Furthermore, the most recent version of the microaxial flow pump, Impella 5.5, provides greater support and reduces device‐related complications in the setting of VA‐ECMO with Impella support compared with Impella CP or 2.5 via femoral artery, and the use of Impella 5.5 continues to grow in HT candidates.…”

Section: Discussionmentioning

confidence: 99%

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Impact of Left Ventricular Unloading on Outcome of Heart Transplant Bridging With Extracorporeal Membrane Oxygenation Support in New Allocation Policy

Gregory,

Okumura,

Isath

et al. 2024

JAHA

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Background The new heart allocation policy places veno‐arterial extracorporeal membrane oxygenation (VA‐ECMO)‐supported heart transplant (HT) candidates at the highest priority status. Despite increasing evidence supporting left ventricular (LV) unloading during VA‐ECMO, the effect of LV unloading on transplant outcomes following bridging to HT with VA‐ECMO remains unknown. Methods and Results From October 18, 2018 to March 21, 2023, 624 patients on VA‐ECMO at the time of HT were identified in the United Network for Organ Sharing database and were divided into 2 groups: VA‐ECMO alone (N=384) versus VA‐ECMO with LV unloading (N=240). Subanalysis was performed in the LV unloading group: Impella (N=106) versus intra‐aortic balloon pump (N=134). Recipient age was younger in the VA‐ECMO alone group (48 versus 53 years, P =0.018), as was donor age (VA‐ECMO alone, 29 years versus LV unloading, 32 years, P =0.041). One‐year survival was comparable between groups (VA‐ECMO alone, 88.0±1.8% versus LV unloading, 90.4±2.1%; P =0.92). Multivariable Cox hazard model showed LV unloading was not associated with posttransplant mortality after HT (hazard ratio, 0.92; P =0.70). Different LV unloading methods had similar 1‐year survival (intra‐aortic balloon pump, 89.2±3.0% versus Impella, 92.4±2.8%; P =0.65). Posttransplant survival was comparable between different Impella versions (Impella 2.5, versus Impella CP, versus Impella 5.0, versus Impella 5.5). Conclusions Under the current allocation policy, LV unloading did not impact waitlist outcome and posttransplant survival in patients bridged to HT with VA‐ECMO, nor did mode of LV unloading. This highlights the importance of a tailored approach in HT candidates on VA‐ECMO, where routine LV unloading may not be universally necessary.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Impact of Left Ventricular Unloading on Outcome of Heart Transplant Bridging With Extracorporeal Membrane Oxygenation Support in New Allocation Policy

Gregory,

Okumura,

Isath

et al. 2024

JAHA

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“…The choice of the appropriate percutaneous ventricular assist device (PVAD) system, the timing of the implant, the duration of support and the prevention of any complications are the key points in the management of patients requiring the insertion of MCADs [8]. Nevertheless, the scientific evidence remains controversial and based on the experience of each centre, leading to significant variability in indications, recommendations and implantation techniques [9,10]. Despite this variability, PVAD implants in the catheterisation laboratory has taken place with promising implications for the future.…”

Section: Introductionmentioning

confidence: 99%

Modelling and Simulation of the Combined Use of IABP and Impella as a Rescue Procedure in Cardiogenic Shock: An Alternative for Non-Transplant Centres?

De Lazzari,

Capoccia,

Badagliacca

et al. 2023

Bioengineering

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The treatment of critically ill patients remains an evolving and controversial issue. Mechanical circulatory support through a percutaneous approach for the management of cardiogenic shock has taken place in recent years. The combined use of IABP and the Impella 2.5 device may have a role to play for this group of patients. A simulation approach may help with a quantitative assessment of the achievable degree of assistance. In this paper, we analyse the interaction between the Impella 2.5 pump applied as the LVAD and IABP using the numerical simulator of the cardiovascular system developed in our laboratory. Starting with pathological conditions reproduced using research data, the simulations were performed by setting different rotational speeds for the LVAD and driving the IABP in full mode (1:1) or partial mode (1:2, 1:3 and 1:4). The effects induced by drug administration during the assistance were also simulated. The haemodynamic parameters under investigation were aa follows: mean aortic pressure, systolic and diastolic aortic pressure, mean pulmonary arterial pressure, mean left and right atrial pressure, cardiac output, cardiac index, left and right ventricular end-systolic volume, left ventricular end-diastolic volume and mean coronary blood flow. The energetic variables considered in this study were as follows: left and right ventricular external work and left and right atrial pressure-volume area. The outcome of our simulations shows that the combined use of IABP and Impella 2.5 achieves adequate support in the acute phase of cardiogenic shock compared to each standalone device. This would allow further stabilisation and transfer to a transplant centre should the escalation of treatment be required.

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“…We have read the review article entitled “Controversies in ECMO: Immediate versus Watchful Waiting for VA-ECMO Venting” by Cavayas and colleagues, 1 published in the Special Issue of Invited Presentations: Adult: Mechanical Circulatory Support: Invited Expert Opinions of JTCVS Open December 2021. We congratulate the authors for this nice review article and, at the same time, provide some personal comments.…”

mentioning

confidence: 99%

“…Cavayas and colleagues 1 further declared that the LV can often be “medically” unloaded. Nevertheless, this statement might lead to underestimation of the current issue.…”

mentioning

confidence: 99%

Unloading the left ventricle in venoarterial extracorporeal life support: The urgent need of speaking the same language!

Meani¹,

Kowalewski²,

Raffa³

et al. 2022

JTCVS Open

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Controversies in extracorporeal membrane oxygenation: Immediate versus watchful waiting for venoarterial extracorporeal membrane oxygenation venting

Cited by 7 publications

References 31 publications

Impact of Left Ventricular Unloading on Outcome of Heart Transplant Bridging With Extracorporeal Membrane Oxygenation Support in New Allocation Policy

Impact of Left Ventricular Unloading on Outcome of Heart Transplant Bridging With Extracorporeal Membrane Oxygenation Support in New Allocation Policy

Modelling and Simulation of the Combined Use of IABP and Impella as a Rescue Procedure in Cardiogenic Shock: An Alternative for Non-Transplant Centres?

Unloading the left ventricle in venoarterial extracorporeal life support: The urgent need of speaking the same language!

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