Extracorporeal Membrane Oxygenation in Adults With Cardiogenic Shock

Abstract

A 28-year-old previously healthy woman was brought to the hospital after out-of-hospital resuscitated cardiac arrest attributable to ventricular fibrillation. On the evening of presentation, she was found unconscious at home by family members. Bystander cardiopulmonary resuscitation (CPR) was immediately initiated. The patient was defibrillated in the field by emergency medical response providers with return of spontaneous circulation. She aspirated during intubation in the field, and arrived to the hospital in shock, with blood pressure 88/71 mm Hg on norepinephrine 20 μg/min and vasopressin 0.04 U/min. She did not have purposeful movements, and therapeutic hypothermia was initiated in the Emergency Department. She had a metabolic acidosis and concomitant type I acute respiratory failure, with PaO 2 66 mm Hg on volume-cycled assist/control mode with tidal volumes of 400 cc, FiO 2 1.0, positive end-expiratory pressure 10 cm H 2 O, and a respiratory rate of 26 breaths/min. Her ECG did not demonstrate stigmata of ischemia or infarction. However, a type I Brugada pattern was noted in leads V1 and V2 before cooling.Over the ensuing several hours, vasopressor requirements escalated. A SwanGanz catheter demonstrated severely depressed cardiac index and elevated pulmonary capillary wedge pressure. She remained severely hypoxic despite maximal ventilator support. Chest x-ray showed diffuse bilateral pulmonary infiltrates, consistent with severe aspiration pneumonitis. PaO 2 decreased to 49 mm Hg despite increased positive end-expiratory pressure and chemical paralysis, meeting Berlin criteria for severe acute respiratory distress syndrome. 1 Options for percutaneous hemodynamic support were considered (including extracorporeal membrane oxygenation [ECMO] or percutaneous ventricular assist device [VAD], such as Impella and TandemHeart), and the patient was placed on veno-arterial ECMO (VA ECMO) for both hemodynamic and respiratory rescue 6 hours after presentation.Cardiopulmonary bypass was first developed in 1954 to facilitate openheart surgery and used successfully 1 year later. 2,3 Although substantially different from early cardiopulmonary bypass systems, ECMO evolved from cardiopulmonary bypass and provides prolonged cardiopulmonary support outside of the operating suite. With increasing technological advances and safety, the uses of ECMO have expanded, with increasing interest as combined shortterm circulatory and respiratory support in patients with cardiogenic shock. 4 Although potentially life-saving, ECMO is invasive, complex, resource intensive, and can be associated with serious complications. This Clinician Update will introduce ECMO technology, review indications and contraindications, discuss management, including maintaining and weaning support, and underscore potential complications.

Tachycardiomyopathy and Extracorporeal Membrane Oxygenation: A Case Report

“…2 Extracorporeal Membrane Oxygenation (ECMO) is a mechanical device that ensures blood oxygenation and perfusion of the main organs for prolonged periods of time in patients with lung and/or heart failure. 4 The use of this device allows the patient to remain alive and hemodynamically stable, working as a bridge to eventual recovery, transplantation, decision-making or even as a "bridge to another bridge" (for instance, as a bridge to left ventricular assist device -LVAD -as target therapeutics).…”

“…4 The authors describe a case of a patient with cardiogenic shock secondary to TCM where the use of ECMO was very important in her evolution.…”

Mechanical circulatory support

“…Extracorporeal circulatory life support (ECLS) or extracorporeal membrane oxygenation (ECMO) are reliable TCS methods that can be easily established in any emergency situation [8]. ECMO can also ensure adequate oxygenation in patients with ACS presenting with acute pulmonary edema.…”

“…Rescue Therapy e the use of a durable device to support resolution from an acute event without major previous cardiac dysfunction. 8. Other.…”

Left ventricular distention under venoarterial extracorporeal membrane oxygenation support: when should we consider percutaneous left heart decompression?

“…Although development of pharmacological therapies along with advances in mechanical circulatory support facilities have led to a substantial reduction of its mortality rate, cardiogenic shock still carries a poor prognosis (2,3). VA-ECMO is widely used for oxygenation and circulatory support for neonates, children and adults whose hearts and lungs can no longer provide adequate physiologic support despite conventional therapies (4)(5)(6). In these patients, VA-ECMO may be considered as a bridge to recovery, to left ventricular assist device (LVAD) implantation or to heart transplantation (5).…”