Protracted aortic valve closure during peripheral veno-arterial extracorporeal life support: is intra-aortic balloon pump an effective solution?

Abstract

IABP placement was an effective solution in order to reverse the protracted AV closure and impaired LV unloading observed during peripheral V-A ECMO support. However, the impact on the weaning rate and survival needs further investigations.

Left Ventricle Unloading with Veno-Arterial Extracorporeal Membrane Oxygenation for Cardiogenic Shock. Systematic Review and Meta-Analysis

“…In Truby et al [33] the clinical and subclinical (not warranting immediate decompression) LV distension occurred in 7% and 22% of patients, respectively. Among 184 peripheral VA ECMO in the series of Meani et al [36], 5.4% required IABP placement because of a protracted closure of the aortic valve.…”

“…The IABP acts with several "indirect" mechanisms reducing both the LV afterload (enhanced systolic ejection) and the LV end-diastolic pressure (enhanced left atrial and pulmonary venous unloading). The IABP induces the aortic valve opening [36], improves coronary and abdominal circulation [38], allows pulsatility in end organ capillary bed [39], it is easy to implant and has contained costs. In animal studies the role of counterpulsation in VA-ECMO support seems controversial.…”

Transaortic or Pulmonary Artery Drainage for Left Ventricular Unloading in Venoarterial Extracorporeal Life Support: A Porcine Cardiogenic Shock Model

“…LV overload assessment should be carefully evaluated in each patient supported with V-A ECLS due to CS. The combination of clinical, echocardiographic and instrumental parameters is crucial in this assessment 8 . As shown in the current study, PA drainage and Impella are differently able to influence specific conditions occurring when LV is overloaded.…”

“…PVA is the total mechanical energy performed by the ventricle per heartbeat, which is the sum of SW (external active forces) and potential energy (PE, internal passive forces) 8 .…”

“…In case of extreme overload and severe LV dysfunction, such a condition may lead to protracted aortic valve closure even during systole, causing blood stasis in the LV, LA, and aortic root, thus increasing the risk of thrombi formation 7 . It is therefore clear that the extent of LV unloading, and aortic valve opening should be continuously monitored to timely alert the attending personnel about such a potential negative impact of V-A ECLS on LV performance and indicate the actual need for less or more aggressive maneuvers to facilitate LV decompression 8 .…”