Left ventricular unloading and the role of ECpella

Abstract

The main reason for the emergency implantation of venoarterial extracorporeal membrane oxygenation (VA-ECMO) is the restoration of adequate systemic perfusion, while protecting the failing heart and promoting myocardial recovery are equally important goals. Following initial haemodynamic stabilization and often the urgent revascularization of the culprit lesion, the clinical focus is then directed towards the most efficient strategy for cardioprotection. Frequent echocardiography measurements may help to estimate the degree of unwanted left ventricular (LV) overloading during VA-ECMO. Additionally, the estimation of high LV filling pressures by Doppler echocardiography or their (in-)direct measurement using a dedicated surgical left atrial pressure line and conventional pulmonary artery catheter in a wedge position or a pigtail catheter in the left ventricle can be performed. Mechanical overload of the left ventricle is the major adverse effect and an obvious mechanistic and prognostic challenge of contemporary ECMO care. Many efforts are under way to overcome this phenomenon by LV unloading, which was effectively achieved by the current combined approach using an axial decompression device, while novel technical developments and approaches are tested and urgently anticipated. The aim of this report is to introduce in depth pathophysiological background, current concepts, and future perspectives in LV unloading strategies.

Impact of left ventricular unloading using a peripheral Impella®‐pump in eCPR patients

“…Previously, early LV‐unloading has been reported to be beneficial in cardiogenic shock patients treated with ECMO via the reduction in left ventricular preload 17,19 . LV‐unloading with Impella® has been shown to provide a most definite LV‐ decompression, compared to V‐A ECMO alone and other venting or unloading devices 20 …”

“…17,19 LV-unloading with Impella® has been shown to provide a most definite LV-decompression, compared to V-A ECMO alone and other venting or unloading devices. 20 Also, the significantly lower low-flow time and the although not statistically significant higher rate of bystander CPR might have contributed to the improved outcomes in the ECMO+Impella® group since shorter low-flow times are associated with improved outcomes in patients that underwent CPR and ECMO cannulation. 21 Other mechanical support devices might also improve mortality and outcome.…”

Secondary left heart failure occurred during VA-ECMO assistance for severe residual pulmonary hypertension after pulmonary endarterectomy: a case report

“…Femoral peripheral VA-ECMO provides full haemodynamic support for patients but increases the afterload to the LV, attributable to retrograde aortic perfusion [ 5 ]. It’s reported that left ventricular overload at any time during VA-ECMO may occur in up to 70% of patients [ 6 ]. This could jeopardize myocardium and negatively affect survival.…”

“…What’s more, the Impella, a trans-aortic LV assist device designed as a catheter-based, micro-axial impeller pump, can provide continuous blood flow from the LV into the ascending aorta, yielding very powerful LV unloading effects. A survival benefit and improved bridging to recovery when combining the Impella with VA ECMO were reported [ 3 , 6 ]. For those diagnosed with DDf after surgery, continued and careful monitoring should be managed to prevent hypoxemia and atrial fibrillation, which are most common complications postoperatively.…”

Algorithmic management of postcardiotomy shock with mechanical support: Bring a map, a plan, and your parachute—and know how to use all three

“…LV decompression reduces myocardial strain, improves myocardial perfusion, and correlates with improved outcomes. 19,20 LV decompression prevents acute lung injury, which significantly affects survival. 21 The Impella allows efficient LV decompression and has been shown to be a valuable adjunct to ECMO or "EC-PELLA," improving survival by 21% over VA-ECMO alone.…”