Management of Peripheral Venoarterial Extracorporeal Membrane Oxygenation in Cardiogenic Shock

Abstract

Objectives: Cardiogenic shock is a highly morbid condition in which inadequate end-organ perfusion leads to death if untreated. Peripheral venoarterial extracorporeal membrane oxygenation is increasingly used to restore systemic perfusion despite limited understanding of how to optimally titrate support. This review provides insights into the physiologic basis of extracorporeal membrane oxygenation support and presents an approach to extracorporeal membrane oxygenation management in the cardiogenic shock patient. Data Sources, Study Selection, and Data Extraction: Data were obtained from a PubMed search of the most recent medical literature identified from MeSH terms: extracorporeal membrane oxygenation, cardiogenic shock, percutaneous mechanical circulatory support, and heart failure. Articles included original articles, case reports, and review articles. Data Synthesis: Current evidence detailing the use of extracorporeal membrane oxygenation to support patients in cardiogenic shock is limited to isolated case reports and single institution case series focused on patient outcomes but lacking in detailed approaches to extracorporeal membrane oxygenation management. Unlike medical therapy, in which dosages are either prescribed or carefully titrated to specific variables, extracorporeal membrane oxygenation is a mechanical support therapy requiring ongoing titration but without widely accepted variables to guide treatment. Similar to mechanical ventilation, extracorporeal membrane oxygenation can provide substantial benefit or induce significant harm. The widespread use and present lack of data to guide extracorporeal membrane oxygenation support demands that intensivists adopt a physiologically-based approach to management of the cardiogenic shock patient on extracorporeal membrane oxygenation. Conclusions: Extracorporeal membrane oxygenation is a powerful mechanical circulatory support modality capable of rapidly restoring systemic perfusion yet lacking in defined approaches to management. Adopting a management approach based physiologic principles provides a basis for care.

Der kardiogene Schock

“…Die Rückgabe erfolgt dabei entweder über die Femoralarterie in die A. iliaca communis oder via chirurgischem Zugang (Patch) in die Aorta descendens oder die A. subclavia. ECLS-Systeme können effektiv im kardiogenen Schock wie auch beim kompletten Herz-Kreislaufstillstand unter Reanimation (eCPR) eingesetzt werden [14]. Vorteil ist die zusätzliche Oxygenierung und Decarboxylierung des Blutes im Gegensatz zur reinen hämodynamischen Unterstützung der zuvor aufgeführten Devices, es fehlt jedoch eine Volumen-Entlastung des linken Ventrikels.…”

Noteworthy Literature From 2019 for Cardiothoracic Critical Care

“…37 Similarly, VA ECMO continues to be used in cases of circulatory shock, 38 particularly cardiogenic shock, though studies on efficacy and outcomes are still primarily limited to single-center case series, and clinical management remains heterogeneous in the setting of a dearth of strong studies or guidelines. 39 In the past year, larger analyses have attempted to better characterize patient outcomes in both VV and VA ECMO.…”

Left ventricle unloading strategies in ECMO: A single‐center experience

“…Extracorporeal membrane oxygenation (ECMO) is increasingly employed to provide mechanical circulatory support (MCS) despite the incomplete understanding of its effects on the failing heart and lack of evidence‐based approaches to mitigating harmful sequelae from its use 1‐4 . Deployed as an MCS device, ECMO shunts venous blood through a membrane oxygenator via a pump before returning oxygenated blood to the systemic arterial system 5,6 .…”

“…Extracorporeal membrane oxygenation (ECMO) is increasingly employed to provide mechanical circulatory support (MCS) despite the incomplete understanding of its effects on the failing heart and lack of evidencebased approaches to mitigating harmful sequelae from its use. [1][2][3][4] Deployed as an MCS device, ECMO shunts venous blood through a membrane oxygenator via a pump before returning oxygenated blood to the systemic arterial system. 5,6 Cannulation strategies for returning oxygenated blood include: (a) central cannulation of the aortic arch to provide antegrade perfusion, most commonly performed for cardiac surgical patients unable to wean from cardiopulmonary bypass, and (b) peripheral cannulation, typically via percutaneous access or vascular cutdown of the femoral artery, in which the cannula terminates in the iliac artery or distal aorta to provide retrograde perfusion.…”

“…Medical therapy to maintain forward flow through the LV consists of optimizing preload and afterload and use of inotropes to augment contractility 3 . In cases in which medical therapy is insufficient or not tolerated, mechanical means of unloading the LV are considered.…”