Venoarterial extracorporeal membrane oxygenation in cardiogenic shock: indications, mode of operation, and current evidence

Abstract

Purpose of review: Temporary circulatory support (TCS) with venoarterial extracorporeal membrane oxygenation (VA-ECMO) is increasingly used as a salvage therapy for patients with refractory cardiogenic shock. This article provides an overview of VA-ECMO principles, indications, management, complications and discusses the results of recent case series and trials. Recent findings: VA-ECMO is utilized as a bridge to "decision" that includes weaning after cardiac function recovery, transplantation, long-term mechanical circulatory support and withdrawal in case of futility. VA-ECMO is considered the first-line TCS since it allows rapid improvement in oxygenation, is less expensive, and is also suitable for patients with biventricular failure. Combining Impella or intra-aortic balloon pump support with VA-ECMO might decrease left ventricular pressure and improve outcomes. Massive pulmonary embolism, sepsis-associated cardiomyopathy, refractory cardiac arrest are among emerging indications for TCS. Summary: TCS have become the cornerstone of the management of patients with cardiogenic shock, although the evidence supporting their efficacy is limited. VA-ECMO is considered the first-line option, with a growing number of accepted and emerging indications. Randomized clinical trials are now needed to determine the place VA-ECMO in cardiogenic shock treatment strategies.

Outcomes of Severe Systemic Rheumatic Disease Patients Requiring Extracorporeal Membrane Oxygenation

“…When end-organ lung or heart failure occurs, the capacity to recover is uncertain, especially for chronic SRD involvement, even with the latest therapeutic innovations. ECMO is an emerging rescue therapy, whose indications for VV [13] or VA hook-up [14] have not yet been clearly delineated. Data are urgently awaited to support or refute the indication of ECMO for SRD patients.…”

Temporary circulatory support for cardiogenic shock

“…121,122 Doppler echocardiographic assessment should occur daily, including formal evaluation for weaning when clinically appropriate. 123,124 Absolute contraindications to TCS device use include irrever sible cardiac failure, if heart transplan tation or longterm VAD is not an option, or irreversible non-cardiac organ failure limiting survival (eg, moribund state, severe anoxic brain injury, or untreatable metastatic cancer).…”

Advanced heart failure with reduced ejection fraction

“…It provides support for cardiac output and has become an important therapy for cardiogenic shock, functioning as a parallel circuit to the patient's heart and lungs. [15][16][17] Accepted indications include shock associated with acute myocardial infarction, myocarditis, intoxication with cardiotoxic drugs, acutely decompensated cardiomyopathies, post cardiotomy, postpartum cardiomyopathy, recurrent lifethreatening arrhythmias, and posttransplantation shock when refractory to conventional management. 14,18,19 VA ECMO has developed a prominent role in management of rapidly progressing heart failure noted as class 1 or 2 of the Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) or even in patients with cardiac arrest requiring cardiopulmonary resuscitation.…”

“…15,21,22 Compared to other active mechanical circulatory support devices, VA ECMO can be less expensive, allows rapid improvement, and is the only shortterm device suitable for severe biventricular failure. 17,23 A major disadvantage of this therapy is the lack of ventricular unloading due to creation of elevated afterload, increasing oxygen demand, and wall tension of the myocardium; in addition, blood stasis in the left ventricle will lead to pulmonary edema. 21,23 Moreover, there are multiple strategies that could provide left ventricular unloading, like central percutaneous cannulation of the left atrium or ventricle or insertion of an Impella pump (Abiomed, Danvers, MA) inside the left ventricle.…”