Outcomes of left ventricular unloading with a transseptal cannula during extracorporeal membrane oxygenation in adults

Kim, Ah-Ram; Park, Hanbit; Lee, Sang-Eun; Ahn, Jung‐Min; Park, Duk‐Woo; Lee, Seung-Whan; Kim, Jae‐Joong; Park, Seung‐Jung; Hong, Jong Chul; Kang, Pil Je; Jung, Sung-Ho; Kim, Minseok

doi:10.1111/aor.13838

Cited by 12 publications

(12 citation statements)

References 34 publications

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“…experienced in the application of this procedure perform all of the transseptal left atrial cannulations in a catheterization room, under intracardiac echocardiographic guidance whenever possible. The complication rates were not high in observational studies 28,29 . However, we are concerned about safety due to the invasive nature of the technique.…”

Section: Discussionmentioning

confidence: 99%

“…Although the number of participants may be too low for mortality evaluation, we calculated the sample size based on the highest‐quality meta‐analyses published to date 16,17 . Also, the mortality rate reductions afforded by transseptal left atrial cannulation reported in observational studies and meta‐analyses are in agreement 16,17,28,29 . In one retrospective data, the 30‐day mortality was 34.4% in conventional group and 5.6% in early routine group 29 .…”

Section: Discussionmentioning

confidence: 99%

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Early left ventricular unloading after extracorporeal membrane oxygenation: rationale and design of EARLY‐UNLOAD trial

et al. 2023

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Aims The clinical benefits of venoarterial extracorporeal membrane oxygenation (VA‐ECMO) for profound cardiogenic shock are well known. However, peripheral VA‐ECMO increases the left ventricular afterload, thus compromising myocardial recovery. Recent studies have revealed the benefit of left ventricular unloading using various methods applied at different times. The EARLY‐UNLOAD trial compares the clinical outcomes of early left ventricular unloading and conventional approach after VA‐ECMO. Methods and results The EARLY‐UNLOAD trial is a single‐centre, open‐label, randomized trial that recruited 116 patients with cardiogenic shock undergoing VA‐ECMO. Patients meeting the inclusion criteria were randomized in a 1:1 ratio to two groups: routine left ventricular unloading via intracardiac echocardiography‐guided transseptal left atrial cannulation within 12 h of VA‐ECMO initiation or conventional approach that indicates rescue left ventricular unloading if clinical signs of an increased left ventricular afterload are present. The primary endpoint is the cumulative incidence of all‐cause death within 30 days, and patients will be followed‐up for 12 months. A key secondary endpoint is a composite measure of all‐cause death and rescue transseptal left atrial cannulation in the conventional group (suggestive of VA‐ECMO treatment failure) within 30 days. The enrolment of patients was finished in September 2022. Conclusions The EARLY‐UNLOAD trial is the first randomized controlled trial to compare early left ventricular unloading and conventional approach after VA‐ECMO using the same unloading modality. The results could impact clinical practice to overcome the haemodynamic issues associated with VA‐ECMO.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Early left ventricular unloading after extracorporeal membrane oxygenation: rationale and design of EARLY‐UNLOAD trial

et al. 2023

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“…Previous studies demonstrated that this LA cannulation decreases LA pressure with a low risk of complications and is associated with better ECMO weaning rates. 8,13,14,22 Therefore, we considered a percutaneous transseptal venous drain cannula to be a good alternative method for LV unloading.…”

Section: Left Ventricular Unloading During Va-ecmomentioning

confidence: 99%

Early left atrial venting versus conventional treatment for left ventricular decompression during venoarterial extracorporeal membrane oxygenation support: The EVOLVE‐ECMO randomized clinical trial

Park,

Yang,

Ahn

et al. 2023

European J of Heart Fail

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AimsFew studies have reported data on the optimal timing of left ventricular (LV) unloading during venoarterial extracorporeal membrane oxygenation (VA‐ECMO) for cardiac arrest or shock. This study evaluated the feasibility of an early LV unloading strategy compared with a conventional strategy in VA‐ECMO.Methods and resultsBetween December 2018 and August 2022, 60 patients at two institutions were randomized in a 1:1 ratio to receive early (n = 30) or conventional (n = 30) LV unloading strategies. The early LV unloading strategy was defined as LV unloading performed at the time of VA‐ECMO insertion. LV unloading was performed using a percutaneous transseptal left atrial cannulation via the femoral vein incorporated into the ECMO venous circuit. The early and conventional LV unloading groups included 29 (96.7%) and 23 (76.7%) patients, respectively (median time from VA‐ECMO insertion to LV unloading: 48.4 h, interquartile range 47.8–96.5 h). The groups showed no significant differences in the rate of VA‐ECMO weaning as the primary endpoint (70.0% vs. 76.7%; relative risk 0.91; 95% confidence interval 0.67–1.24; p = 0.386) and survival to discharge (53.3% vs. 50.0%, p = 0.796). However, the pulmonary congestion score index at 48 h after LV unloading was significantly improved only in the early LV unloading group (2.0 ± 0.7 vs. 1.7 ± 0.6 at baseline vs. at 48 h; p = 0.008).ConclusionsCompared with the conventional approach, early LV unloading did not improve the VA‐ECMO weaning rate, despite the rapid improvement in pulmonary congestion. Therefore, the results of this study do not support the application of this strategy after VA‐ECMO insertion.

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“…In 2021, Kim et al published the first controlled retrospective trial ( n = 124) on outcomes with active percutaneous LA venting compared to patients with an arterial pulse pressure of < 10 mmHg who were treated with isolated VA-ECMO [ 25 ] (Table 2 ). Regarding baseline characteristics in both groups, the authors reported considerable differences: Patients receiving LA venting were younger, less likely to have suffered prior cardiac arrest and more likely to present with acute decompensated heart failure as VA-ECMO indication.…”

Section: Active Left Atrial Ventingmentioning

confidence: 99%

“…Although Kim et al and Ok et al did not observe significant differences in complication rates between venting and control groups (12.9% vs. 11.3%, p = 0.783 and 29% vs. 8.9%, p = 0.26, respectively), one patient experienced cardiac tamponade after the procedure [ 25 ]. Other complications of LA venting included catheter obstruction [ 28 ], drain malpositioning [ 26 ], cardiac perforation [ 36 ], persistent left-to-right shunt after cannula explantation [ 29 , 31 , 33 ], as well as insertion-site bleeding and infection [ 23 ].…”

Section: Active Left Atrial Ventingmentioning

confidence: 99%

Venting during venoarterial extracorporeal membrane oxygenation

et al. 2022

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Cardiogenic shock and cardiac arrest contribute pre-dominantly to mortality in acute cardiovascular care. Here, veno-arterial extracorporeal membrane oxygenation (VA-ECMO) has emerged as an established therapeutic option for patients suffering from these life-threatening entities. VA-ECMO provides temporary circulatory support until causative treatments are effective and enables recovery or serves as a bridging strategy to surgical ventricular assist devices, heart transplantation or decision-making. However, in-hospital mortality rate in this treatment population is still around 60%. In the recently published ARREST trial, VA-ECMO treatment lowered mortality rate in patients with ongoing cardiac arrest due to therapy refractory ventricular fibrillation compared to standard advanced cardiac life support in selected patients. Whether VA-ECMO can reduce mortality compared to standard of care in cardiogenic shock has to be evaluated in the ongoing prospective randomized studies EURO-SHOCK (NCT03813134) and ECLS-SHOCK (NCT03637205). As an innate drawback of VA-ECMO treatment, the retrograde aortic flow could lead to an elevation of left ventricular (LV) afterload, increase in LV filling pressure, mitral regurgitation, and elevated left atrial pressure. This may compromise myocardial function and recovery, pulmonary hemodynamics—possibly with concomitant pulmonary congestion and even lung failure—and contribute to poor outcomes in a relevant proportion of treated patients. To overcome these detrimental effects, a multitude of venting strategies are currently engaged for both preventive and emergent unloading. This review aims to provide a comprehensive and structured synopsis of existing venting modalities and their specific hemodynamic characteristics. We discuss in detail the available data on outcome categories and complication rates related to the respective venting option. Graphical abstract

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Outcomes of left ventricular unloading with a transseptal cannula during extracorporeal membrane oxygenation in adults

Cited by 12 publications

References 34 publications

Early left ventricular unloading after extracorporeal membrane oxygenation: rationale and design of EARLY‐UNLOAD trial

Early left ventricular unloading after extracorporeal membrane oxygenation: rationale and design of EARLY‐UNLOAD trial

Early left atrial venting versus conventional treatment for left ventricular decompression during venoarterial extracorporeal membrane oxygenation support: The EVOLVE‐ECMO randomized clinical trial

Venting during venoarterial extracorporeal membrane oxygenation

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