Left ventricular unloading during veno-arterial ECMO: a review of percutaneous and surgical unloading interventions

Abstract

Short-term mechanical support by veno-arterial extracorporeal membrane oxygenation (VA ECMO) is more and more applied in patients with severe cardiogenic shock. A major shortcoming of VA ECMO is its variable, but inherent increase of left ventricular (LV) mechanical load, which may aggravate pulmonary edema and hamper cardiac recovery. In order to mitigate these negative sequelae of VA ECMO, different adjunct LV unloading interventions have gained a broad interest in recent years. Here, we review the whole spectrum of percutaneous and surgical techniques combined with VA ECMO reported to date.

Contradictory responses of the microcirculation to changes in extracorporeal membrane oxygenation pump flow in patients on venoarterial extracorporeal membrane oxygenation: a prospective observational study

“…First, a higher VA-ECMO pump flow rate causes a larger reduction in cardiac preload, stroke volume, and pulse pressure, and a larger increase in cardiac afterload [20]. This reminds us that a VA-ECMO pump flow rate that is too high may contribute to decreased cardiac output and left ventricular overload [27][28][29].…”

Extracorporeal Membrane Oxygenation: The New Jack-of-All-Trades?

“…Thus LV venting strategies to avoid events related to LV distention are an essential component of VA-ECMO and are listed in Table 14. 72,91,93,94 Intra-aortic balloon pump improves LV distention by increasing stroke volume with some unloading effect, which could be beneficial in the setting of a persistently non-ejecting LV. 94 The challenge of atrial septostomy is creating an appropriately sized, well-defined defect.…”

“…72,91,93,94 Intra-aortic balloon pump improves LV distention by increasing stroke volume with some unloading effect, which could be beneficial in the setting of a persistently non-ejecting LV. 94 The challenge of atrial septostomy is creating an appropriately sized, well-defined defect. 94 A well-defined defect allows for potential future use of a percutaneous closure device.…”

“…94 The challenge of atrial septostomy is creating an appropriately sized, well-defined defect. 94 A well-defined defect allows for potential future use of a percutaneous closure device. Left atrial or left ventricular cannulation allows for controlled decompression but comes with the challenges of managing an indwelling catheter: cannula movement, kinking, thrombosis, and patient immobility.…”

Venoarterial extracorporeal membrane oxygenation in elective high-risk percutaneous coronary intervention: a viable option?

“…These may include the possibility for adequate analgosedation and delivery of positive end-expiratory pressure, which could prevent the development of overt pulmonary oedema. If high ECMO flow rates would inevitably result in left ventricular overload, functional and structural myocardial compromise and pulmonary oedema (and the related risk of the so-called Harlequin syndrome), left ventricular unloading strategies may be warranted [1,10].…”