Mechanical circulatory support in cardiogenic shock

Werdan, Karl; Gielen, Stephan; Ebelt, Henning; Hochman, Judith S.

doi:10.1093/eurheartj/eht248

Cited by 387 publications

(288 citation statements)

References 75 publications

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“…Mortality is high whatever the cause, and despite specific therapies targeted to the primary disorder (revascularisation, surgery, antiarrhythmics and immunosuppressants). So far, it is clear that this syndrome, with a stable mortality rate >40% as reported in most recent literature (1), requires a specific therapy. On top of medical therapy, mechanical circulatory support has emerged as the mainstay treatment for cardiogenic shock (1,2).…”

mentioning

confidence: 91%

Intra-aortic balloon pump during venoarterial extracorporeal membrane oxygenation: still a matter of debate? Contemporary multi-device approach to cardiogenic shock

et al. 2017

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Acute cardiogenic shock still represents a life-threating condition, even though great improvements and innovations have been introduced in the last years in this field. Mortality is high whatever the cause, and despite specific therapies targeted to the primary disorder (revascularisation, surgery, antiarrhythmics and immunosuppressants). So far, it is clear that this syndrome, with a stable mortality rate >40% as reported in most recent literature (1), requires a specific therapy. On top of medical therapy, mechanical circulatory support has emerged as the mainstay treatment for cardiogenic shock (1,2).Venoarterial extracorporeal membrane oxygenation (VA ECMO) presents unique features which have made it the more suitable device in this context, namely the rapid availability and ease for set up, the high reperfusive flow, the biventricular and pulmonary support provided.As a result of transition from complex and bulky system to simple circuits and machines, it has now become of common use in clinical practice to treat a wide range of shock conditions up to out of hospital refractory cardiac arrest.No large controlled trial has, however, so far addressed the application of VA ECMO in the setting of cardiogenic shock and studies to summarize experiences in managing and running ECMO support are strongly warranted. Some issues of VA ECMO therapy are, indeed, still open: above all, unloading of the left ventricle, which represents the Achilles' heel of this treatment (3). The arterial perfusion provided during peripheral VA ECMO is retrograde, and the increased afterload on the dysfunctional left ventricle may lead to lung overload up to pulmonary oedema (4). This is a detrimental hemodynamic effect, which may jeopardize the benefits of VA ECMO treatment itself.The need for left ventricle venting during VA ECMO has been addressed with several approaches including balloon and blade atrial septostomy, left atrial decompression with transeptal puncture, a surgically placed left ventricular (LV) venting, a percutaneous LV assist device and an intra-aortic balloon pump (IABP). We don't think that IABP is useful during VA ECMO for a supposed "perfusion benefit" which indeed is overcome by ECMO blood flow: on the contrary, the rationale of the combined use of VA ECMO and IABP is to provide a pressure unloading to the left ventricle. As a matter of fact, this mechanical circulatory support should be already in place at the time of VA ECMO implantation, as stated by ELSO Guidelines. As a result, it is not the opportunity of its implantation, rather its removal to be discussed.In the present article (5), the authors analyzed a huge number of ECMO patients from a nationwide inpatient database, including more than 90% of all tertiary-care emergency hospitals in Japan. They compared a group of patients treated with VA ECMO alone with a group of patients who received multidevice mechanical circulatory support with VA ECMO and IABP, using propensity score matching.The primary outcome was all-cause 28-day mortality Editorial Intra-...

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confidence: 91%

Intra-aortic balloon pump during venoarterial extracorporeal membrane oxygenation: still a matter of debate? Contemporary multi-device approach to cardiogenic shock

et al. 2017

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“…2,3 This technique is increasingly used as a short-term circulatory support in patients with RCF, providing a bridge to heart transplant. 4 Venoarterial extracorporeal membrane oxygenation may be used after heart transplant for conditions refractory to medical treatment like primary graft failure. 5 Previously, we reported our experience with patients who received VA-ECMO as a bridge to emergency heart transplant in the intensive care unit (ICU).…”

Section: Introductionmentioning

confidence: 99%

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Gedik

Atar²,

Özdemirkan³

et al. 2017

Exp Clin Transplant

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Objectives: Heart transplant is the only definitive treatment of end-stage heart failure. Venoarterial extracorporeal membrane oxygenation may be used as a bridge to heart transplant. This technique may be used after heart transplant for conditions refractory to medical treatment like primary graft failure. Previously, we reported our experience with patients who received extracorporeal support as a bridge to emergency heart transplant. In this study, we present our perioperative experience with heart transplants in which extracorporeal support was used. Materials and Methods:We retrospectively screened the data of 31 patients who were seen at our center between January 2014 and June 2016. We screened for patients who were admitted to the intensive care unit before transplant and who required venoarterial extracorporeal membrane oxygenation for circulatory support and postoperative patients who required extracorporeal support. Patient demographics and characteristics, clinical data, and extracorporeal support data were collected from our electronic database and patient medical records. Results: There were 14 patients who required perioperative extracorporeal support. Preoperative support was performed in 3 patients before transplant, and postoperative support was performed in 11 patients after transplant. The mean age was 37.7 years in patients within the preoperative group and 29.7 years in patients within the postoperative group. One patient with preoperative support and 5 with postoperative support were pediatric patients. The main indication for transplant was dilated cardiomyopathy in both groups (100% and 63.7%). Overall mortality rates were 33% in the preoperative group and 63.7% in the postoperative group. Conclusions: For patients on heart transplant wait lists who are worsening despite optimal medical therapy, venoarterial extracorporeal membrane oxygenation support is a safe and viable last resort. In addition, extracorporeal support can be used during the posttransplant period as salvage therapy in heart recipients with hemodynamic deterioration. In our experience, preoperative extracorporeal support had lower mortality rates compared with postoperative support.

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“…The advantages of ECMO over other percutaneous devices are its ease of insertion and its ability to support right, left, or biventricular failure at high blood flows. 3 This technique may be used as a bridge to heart transplant in both pediatric and adult patients. 2,4 Venoarterial extracorporeal membrane oxygenation is increasingly used as a short-term circulatory support in patients with RCF, providing a bridge to heart transplant.…”

Section: Introductionmentioning

confidence: 99%

Untitled

2016

Exp Clin Transplant

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Heart transplant is the only definitive treatment of end-stage heart failure. Venoarterial extracorporeal membrane oxygenation may be used as a bridge to heart transplant. Among 31 patients who underwent heart transplant between January 2014 and June 2016, we present our experiences with 3 patients who received venoarterial extracorporeal support as a bridge to heart transplant. The first patient was a 51-year-old male with ischemic dilated cardiomyopathy. Transplant was performed after 6 days of extracorporeal support, and the patient was discharged and alive at follow-up. Patient 2 was a 12-yearold girl with dilated cardiomyopathy who presented with cardiac arrest. Extracorporeal support was initiated during cardiopulmonary resuscitation. She had full neurologic recovery and remained on the wait list. She received a transplant 22 days after resuscitation. She survived and was alive at day 220 posttransplant. The third patient was a 50-year-old male with ischemic dilated cardiomyopathy requiring venoarterial extracorporeal support. Percutaneous balloon atrial septostomy was performed for left ventricle venting. He underwent transplant on day 28 after intensive care unit admission. He died 29 days after release from the hospital. Regarding patients on heart transplant wait lists who are worsening despite optimal medical therapy, venoarterial extracorporeal membrane oxygenation support is a safe and viable last resort.

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Mechanical circulatory support in cardiogenic shock

Cited by 387 publications

References 75 publications

Intra-aortic balloon pump during venoarterial extracorporeal membrane oxygenation: still a matter of debate? Contemporary multi-device approach to cardiogenic shock

Intra-aortic balloon pump during venoarterial extracorporeal membrane oxygenation: still a matter of debate? Contemporary multi-device approach to cardiogenic shock

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