Veno-Arterial Extracorporeal Membrane Oxygenation for Cardiogenic Shock

Abstract

Extracorporeal membrane oxygenation has evolved, from a therapy that was selectively applied in the pediatric population in tertiary centers, to more widespread use in diverse forms of cardiopulmonary failure in all ages. We provide a practical review for cardiovascular clinicians on the application of veno-arterial extracorporeal membrane oxygenation in adult patients with cardiogenic shock, including epidemiology of cardiogenic shock, indications, contraindications, and the extracorporeal membrane oxygenation circuit. We also summarize cannulation techniques, practical management and troubleshooting, prognosis, and weaning and exit strategies, with attention to end of life and ethical considerations.

Update on Weaning from Veno-Arterial Extracorporeal Membrane Oxygenation

“…If a fair perspective is missing, withdrawal of support must be discussed. The weaning strategy of Eckman et al corresponds essentially to that of Keebler et al and uses the same echocardiographic and hemodynamic parameters, so that a more detailed representation is redundant at this point and reference is made to Figure 3 [10]. Of note, the latter emphasize, particular attention must be given to anticoagulation during weaning such as maintaining therapeutic anticoagulation when flow rates are ≤ 2 L/min, since risk of thrombosis increases with lower circuit flow.…”

“…In the latter registry, data on outcome are limited to observational studies and vary significantly depending on underlying indication. Outcome seems to be most beneficial in patients requiring VA-ECMO support for either acute severe myocarditis, pulmonary embolism with RV failure, or primary graft failure after cardiac transplant, with reported survival rates at hospital discharge of up to 80% [10][11][12][13]. Survival to discharge rate in patients undergoing VA-ECMO and percutaneous coronary intervention in cardiogenic shock complicating acute myocardial infarction is reported to be up to 70% [14,15].…”

“…Standardized protocol for weaning from VA-ECMO according to Eckman et al[10]. LV, left ventricle; RV, right ventricle; VTI, velocity-time integral; TDSa, tissue Doppler lateral mitral annulus peak systolic velocity; MCS, mechanical circulatory support.…”

CPR and ECMO: The Next Frontier

“…16 Other common complications include clot and fibrin formation, hemolysis, air embolism, left ventricle overloading, Harlequin syndrome, and limb ischemia. 17…”

“…16 Thrombotic events including stroke (3.8%-6.8%) and limb ischemia (3.6%) are less frequent, while hemorrhagic complications occur in 27%-44% of patients and include a 2.2% risk of intracranial hemorrhage. 17,57 Nonetheless, there is currently not an optimal strategy for anticoagulation management for patients on VA-ECMO. 57 One study compared two anticoagulation targets (activated coagulation time [ACT] target 140-160 seconds versus 180-220 seconds) and found a significantly higher amount of cannula site bleeding, bleeding-induced death, and major bleeding events in the higher-target group.…”