How I approach weaning from venoarterial ECMO

Fried, Justin; Masoumi, Amirali; Takeda, Koji; Brodie, Daniel

doi:10.1186/s13054-020-03010-5

Cited by 27 publications

(21 citation statements)

References 12 publications

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“…In fact, significant reduction of lactates 50 and of the inotropic score 51 flow which has to be viewed in a double perspective. On one hand, Impella is a 'resuscitative' flow, on the other hand, the device allows smoother weaning from mechanical circulatory support 52 . Indeed, ECMO removal is a complex issue: patients will recover aortic pulsatility and normal cardiac output, though echocardiography usually shows low ejection fraction, and this translates into a consistent number of patients who are weaned from ECMO but will eventually die before hospital discharge 53 54 .…”

Section: Ecpella Advantagesmentioning

confidence: 99%

ECPella: Concept, Physiology and Clinical Applications

Meani

Lorusso

Pappalardo

2022

Journal of Cardiothoracic and Vascular Anesthesia

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Section: Ecpella Advantagesmentioning

confidence: 99%

ECPella: Concept, Physiology and Clinical Applications

Meani

Lorusso

Pappalardo

2022

Journal of Cardiothoracic and Vascular Anesthesia

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“…Hemodynamic monitors including right upper extremity arterial line and PA catheter should remain in place for perfusion indices to be trended, ensuring that adequate myocardial recovery has occurred to support the end-organs. 31 , 46 Though there is not a standard-of-care approach to weaning, an algorithmic, step-wise approach is advocated. 31 , 47 Many centers adopt a 3 step approach consisting of daily weaning studies followed by bedside assessment for decannulation and ultimately a formal turn-down study under TEE guidance for decannulation in the operating room.…”

Section: Veno-arterial Extracorporeal Membrane Oxygenationmentioning

confidence: 99%

“…If the patient’s MAP does not fall more than 10 to 15 mm Hg and filling pressures do not significantly increase, the patient is allowed to flow at the lowest tolerated rate and hemodynamics are trended for 8 hours. 46 Daily weaning trials are often performed sequentially with serial TTE examinations as successful weaning is associated with an aortic VTI greater than 10 cm, LVEF greater than 20 to 25%, and lateral mitral annulus peak systolic velocity greater than 6 cm/s 48 Once a daily weaning trial is tolerated, a bedside assessment for decannulation is often performed by decreasing ECMO flow to 1 LPM and hemodynamics are assessed. If well tolerated, the patient may be scheduled for a formal ECMO turn down the study in the operating room whereby ECMO flows will be decreased and the cannulae clamped for 30 minutes, up to 4 hours.…”

Section: Veno-arterial Extracorporeal Membrane Oxygenationmentioning

confidence: 99%

Basics of Extracorporeal Membrane Oxygenation

Wrisinger

Thompson

2022

Surgical Clinics of North America

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“…Due to dissimilarities between the human and sheep thorax anatomy, measurement of out ow tract velocity time integral was not obtained. Yet, to minimize the effect of increased afterload, we obtained our echocardiographic assessments at baseline and at CS, using only 1 L/min of VA-ECMO support to minimize afterload, as is often applied in clinical practice to assess the possibility of weaning patients from VA-ECMO [35]. Secondly, only six animals were evaluated, yet consistent results were found amongst all the evaluated animal subjects.…”

Section: Study Limitationsmentioning

confidence: 99%

An innovative ovine model of severe cardiopulmonary failure supported by veno-arterial extracorporeal membrane oxygenation

Heinsar

Jung

Colombo

et al. 2021

Preprint

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Background Refractory cardiogenic shock (CS), frequently complicated by pulmonary failure, often requires veno-arterial extracorporeal membrane oxygenation (VA-ECMO) to sustain end-organ perfusion. Currently available animal models, such as the coronary ligation model, result in highly variable injury profiles and unacceptably high levels of subsequent ventricular fibrillation, cardiac arrest, and death. As the use of ECMO increases, there is a growing need for a clinically relevant, robust, and titratable model of severe cardiopulmonary failure supported by VA-ECMO. Methods Six sheep (60 ± 6 kg) were anaesthetized, intubated and mechanically ventilated. VA-ECMO was initially carried out at a flow rate of 1 L/min. CS was induced through 1-mL left ventricle myocardial injections of 96% ethanol and confirmed when systolic blood pressure (SBP) was < 90 mmHg and lactate > 4 mmol/L. Then, pulmonary failure was confirmed when PaO2 was < 60 mmHg through substantial decrease in the ventilatory support. Thereafter, VA-ECMO support was increased to obtain a mean arterial pressure of 65 mmHg. Echocardiography and cardiac Troponin I (cTnI) analysis were performed at baseline, upon CS confirmation, establishment of pulmonary failure and hourly thereafter. After 5h, the animals were euthanised and the heart collected for histological and macroscopic assessment. Results Ethanol (58 ± 23 mL) rapidly induced CS in all animals. cTnI levels increased near 5000-fold. SBP decreased from 97 ± 18 mmHg at baseline to 67 ± 14 mmHg upon CS, and lactate from 1.4 ± 0.8 to 4.7 ± 0.9 mmol/L, respectively. Echocardiography studies demonstrated a decrease in the left ventricular fractional area change from 34 ± 9% upon baseline to 16 ± 7% after CS. Analysis of myocardial tissue samples corroborated extensive cellular necrosis and inflammatory infiltrates. Conclusions We present a novel titratable model of severe cardiopulmonary failure in animal on VA-ECMO, through intramyocardial ethanol injections and reduction in ventilatory support. This model could be essential to further characterize left-sided heart failure and develop future treatments.

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How I approach weaning from venoarterial ECMO

Cited by 27 publications

References 12 publications

ECPella: Concept, Physiology and Clinical Applications

ECPella: Concept, Physiology and Clinical Applications

Basics of Extracorporeal Membrane Oxygenation

An innovative ovine model of severe cardiopulmonary failure supported by veno-arterial extracorporeal membrane oxygenation

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