Left ventricle unloading during veno-arterial extracorporeal membrane oxygenation

Abstract

Extracorporeal membrane oxygenation in veno-arterial configuration (VA-ECMO) is a method widely used to support circulation during the most severe conditions of heart failure or refractory cardiac arrest. It frequently bridges this otherwise fatal status to recovery, therapeutic intervention or other circulatory support. However, the use of VA-ECMO in critical situations of severely impaired heart function is associated with specific limitations. One common complication is left ventricular overload and distension, primarily due to the increased afterload caused by extracorporeal blood flow. To date, various techniques has been proposed to decrease left ventricular distension and improve its function, including insertion of intra-aortic balloon pump or percutaneous left ventricular assist device, left atrial and left ventricular venting, or switch to surgically inserted left ventricular support with or without oxygenator. The present review summarizes current minimally invasive approaches to unload overloaded left ventricle during VA-ECMO support.

Relation Between Left Ventricular Unloading During Ecmo and Drainage Catheter Size Assessed by Mathematical Modeling

“…This study was focused on the withdrawn blood volumes from the LV for a one cardiac cycle. One common complication of the ECMO is the LV overload and distention, primarily due to the increased afterload caused by the EBF [2]. The ECMO application causes an increase of end-systolic volume (ESV) and can induce deterioration of LV the function [1].…”

“…In the extreme situation, the aortic valve remains closed even during systole. This results in the LV overload with distension, increased wall stress and increased myocardial oxygen consumption [2]. Insufficient decompression of the left ventricle during the VA-ECMO is considered as a major factor preventing an adequate LV recovery [3].…”

“…The LV decompression, during the ECMO therapy, seems to be associated with a significant improvement of the LV function [4]. The left ventricle can be unloaded by an insertion of a pigtail catheter into the LV through the aortic valve and connected to the inflow line of the ECMO circuit by an Y-shaped connector [2]. Figure 1 shows the unloading method during the ECMO therapy by the catheter inserted in the LV.…”

Strategies for Left Ventricular Decompression During Venoarterial Extracorporeal Membrane Oxygenation - A Narrative Review

“…[7][8][9][10][11][12] Other complications may include intracardiac thrombosis, pulmonary hypertension, pulmonary edema, and reduced likelihood of biventricular recovery and successful weaning from VA-ECMO. [13][14][15][16][17] In order to maximize the likelihood of cardiac recovery, some authors recommend routine left ventricular decompression 18 during VA-ECMO, whereas others propose a more selective approach. 19 The difference in approach may depend on the primary indication for VA-ECMO.…”

Flow Optimization, Management, and Prevention of LV Distention during VA-ECMO

“…Percutaneous VA-ECMO appears fitted to restore peripheral flows when the patient experiences a moderate reduction of cardiac output. When the patient needs higher flows, the risk of pulmonary edema and left ventricular distention increases [22], and additional cares may be necessary to unload the left ventricle and eventually to restore pulmonary function after pulmonary edema [23][24][25].…”