Periprocedural Cardiopulmonary Bypass or Venoarterial Extracorporeal Membrane Oxygenation During Transcatheter Aortic Valve Replacement: A Systematic Review

Abstract

BackgroundThere are limited data on the use of venoarterial extracorporeal membrane oxygenation (VA‐ECMO) or cardiopulmonary bypass (CPB) to provide hemodynamic support periprocedurally during transcatheter aortic valve replacement. This study sought to evaluate patients receiving transcatheter aortic valve replacement with concomitant use of CPB/VA‐ECMO.Methods and ResultsWe systematically reviewed the published literature from 2000 to 2018 for studies evaluating adult patients requiring CPB/VA‐ECMO periprocedurally during transcatheter aortic valve replacement. Studies reporting short‐term and long‐term mortality were included. Given the significant methodological and statistical differences between published studies, meta‐analysis of the association of CPB/VA‐ECMO with mortality was not performed. Of the 537 studies identified, 9 studies representing 5191 patients met our inclusion criteria. Median ages were between 75 and 87 years with 33% to 75% male patients. Where reported, the Edwards SAPIEN™ transcatheter heart valve was the most frequently used. A total of 203 (3.9%) patients received periprocedural hemodynamic support with CPB/VA‐ECMO. Common indications for CPB/VA‐ECMO included left ventricular or aortic annular rupture, rapid hemodynamic deterioration, aortic regurgitation, cardiac arrest, and left main coronary artery obstruction. The use of CPB/VA‐ECMO was predominantly an emergent strategy and was used for durations of 1 to 2 hours. Short‐term mortality (in‐hospital and 30‐day) was 29.8%, and 1‐year mortality was 52.4%. Major complications such as bleeding, vascular injury, tamponade, stroke, and renal failure were noted in 10% to 50% of patients.Conclusions CPB/VA‐ECMO was used in 4% in the early experience of patients undergoing transcatheter aortic valve replacement, most commonly for periprocedural complications. There are limited data on preprocedural planned use of VA‐ECMO, and the characteristics of this population remain poorly defined.

Complications in Patients with Acute Myocardial Infarction Supported with Extracorporeal Membrane Oxygenation

“…In patients with AMI, ECMO is often used to support tenuous hemodynamics during cardiac arrest, cardiopulmonary resuscitation, cardiogenic shock, and high risk coronary intervention [1][2][3][4][5][6][7][8]. However, by virtue of its unique configuration, ECMO is associated with higher left ventricular afterload, greater vascular complications due to large bore access, limb ischemia due to lack of antegrade flow, greater clotting, and thrombocytopenia due to a complex circuit and higher risk of strokes due to variation in anticoagulation [1].…”

“…Extracorporeal membrane oxygenation (ECMO) is increasingly used in acute cardiovascular care for the management of acute myocardial infarction (AMI) complicated by cardiac arrest, cardiogenic shock and complications from cardiac interventional procedures [1][2][3][4][5][6][7][8][9][10]. ECMO provides cardiac output support of nearly 3-5 L, biventricular support and respiratory support, thereby assisting with critical cardiorespiratory support in extreme situations [11].…”

“…ECMO provides cardiac output support of nearly 3-5 L, biventricular support and respiratory support, thereby assisting with critical cardiorespiratory support in extreme situations [11]. Despite limited data and the absence of randomized controlled trials, ECMO has been widely accepted in clinical practice [2][3][4][5][6][7][8]. Despite the stated benefits from ECMO therapy, these acutely ill patients receiving ECMO support for AMI continue to experience high in-hospital mortality [7].…”

Complications from percutaneous-left ventricular assist devices versus intra-aortic balloon pump in acute myocardial infarction-cardiogenic shock

“…However, large-scale randomized trials like IABP-SHOCK II (Intra-aortic balloon counterpulsation in acute myocardial infarction complicated by cardiogenic shock) have demonstrated no difference in AMI-CS outcomes with or without the IABP [5]. Newer devices including TandemHeart, Impella and extracorporeal membrane oxygenation (ECMO) have been introduced into clinical practice in the last 10-15 years, with Impella being the most commonly used today [6][7][8][9][10][11][12][13][14][15][16][17].…”

Transcatheter aortic valve implantation (TAVI) in cardiogenic shock: TAVI‐shock registry results

“…For this reason, it is considered a palliation. On paper, TAVI might be a more reasonable treatment option in this setting, but data on CS patients, with SAS, treated by TAVI are limited to case reports and small series 9,10 and, more important, there are no guideline's recommendation. Another unexplored field is on TAVI in the setting of degenerated aortic bioprosthesis complicated by CS 11‐13 .…”