Assessing Left Ventricular Unloading and Wall Tension to Predict the Need for Durable Mechanical Circulatory Support after Peripheral VA-ECMO

Introduction: The intra-aortic balloon pump (IABP) and Impella are left ventricular unloading devices with peripheral venoarterial extracorporeal membrane oxygenation (VA-ECMO) in place and later serve as bridging therapy when VA-ECMO is terminated. We aimed to determine the potential differences in clinical outcomes and rate of complications between the two combinations of mechanical circulatory support. Methods: This was a retrospective, single institutional cohort study conducted in the intensive care unit (ICU) of Queen Elizabeth Hospital, Hong Kong. Inclusion criteria included all patients aged ⩾18 years, who had VA-ECMO support, and who had left ventricular unloading by either IABP or Impella between January 1, 2018 and October 31, 2020. Patients <18 years old, with central VA-ECMO, who did not require left ventricular unloading, or who underwent surgical venting procedures were excluded. The primary outcome was ECMO duration. Secondary outcomes included length of stay (LOS) in the ICU, hospital LOS, mortality, and complication rate. Results: Fifty-two patients with ECMO + IABP and 14 patients with ECMO + Impella were recruited. No statistically significant difference was observed in terms of ECMO duration (2.5 vs 4.6 days, p = 0.147), ICU LOS (7.7 vs 10.8 days, p = 0.367), and hospital LOS (14.8 vs 16.5 days, p = 0.556) between the two groups. No statistically significant difference was observed in the ECMO, ICU, and hospital mortalities between the two groups. Specific complications related to the ECMO and Impella combination were also noted. Conclusions: Impella was not shown to offer a statistically significant clinical benefit compared with IABP in conjunction with ECMO. Clinicians should be aware of the specific complications of using Impella.

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Venoarterial extracorporeal membrane oxygenation as mechanical circulatory support in adult septic shock: a systematic review and meta-analysis with individual participant data meta-regression analysis

Critical Care ◽

10.1186/s13054-021-03668-5 ◽

2021 ◽

Vol 25 (1) ◽

Author(s):

Ryan Ruiyang Ling ◽

Kollengode Ramanathan ◽

Wynne Hsing Poon ◽

Chuen Seng Tan ◽

Nicolas Brechot ◽

...

Keyword(s):

Septic Shock ◽

Extracorporeal Membrane Oxygenation ◽

Mechanical Circulatory Support ◽

Meta Analysis ◽

Left Ventricular ◽

Adult Patients ◽

Circulatory Support ◽

Venoarterial Extracorporeal Membrane Oxygenation ◽

Refractory Septic Shock ◽

Va Ecmo

Abstract Background While recommended by international societal guidelines in the paediatric population, the use of venoarterial extracorporeal membrane oxygenation (VA ECMO) as mechanical circulatory support for refractory septic shock in adults is controversial. We aimed to characterise the outcomes of adults with septic shock requiring VA ECMO, and identify factors associated with survival. Methods We searched Pubmed, Embase, Scopus and Cochrane databases from inception until 1st June 2021, and included all relevant publications reporting on > 5 adult patients requiring VA ECMO for septic shock. Study quality and certainty in evidence were assessed using the appropriate Joanna Briggs Institute checklist, and the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) approach, respectively. The primary outcome was survival to hospital discharge, and secondary outcomes included intensive care unit length of stay, duration of ECMO support, complications while on ECMO, and sources of sepsis. Random-effects meta-analysis (DerSimonian and Laird) were conducted. Data synthesis We included 14 observational studies with 468 patients in the meta-analysis. Pooled survival was 36.4% (95% confidence interval [CI]: 23.6%–50.1%). Survival among patients with left ventricular ejection fraction (LVEF) < 20% (62.0%, 95%-CI: 51.6%–72.0%) was significantly higher than those with LVEF > 35% (32.1%, 95%-CI: 8.69%–60.7%, p = 0.05). Survival reported in studies from Asia (19.5%, 95%-CI: 13.0%–26.8%) was notably lower than those from Europe (61.0%, 95%-CI: 48.4%–73.0%) and North America (45.5%, 95%-CI: 16.7%–75.8%). GRADE assessment indicated high certainty of evidence for pooled survival. Conclusions When treated with VA ECMO, the majority of patients with septic shock and severe sepsis-induced myocardial depression survive. However, VA ECMO has poor outcomes in adults with septic shock without severe left ventricular depression. VA ECMO may be a viable treatment option in carefully selected adult patients with refractory septic shock.

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Abstract 13425: Comparison Between Impella 5.0 and External Corporeal Left Ventricular Assist Device as a Bridge to Decision in Patients With Cardiogenic Shock

Circulation ◽

10.1161/circ.142.suppl_3.13425 ◽

2020 ◽

Vol 142 (Suppl_3) ◽

Author(s):

Toru Kondo ◽

Naoki Shibata ◽

shingo kazama ◽

Yuki Kimura ◽

Hideo Oishi ◽

...

Keyword(s):

Cardiogenic Shock ◽

Mechanical Circulatory Support ◽

Left Ventricular ◽

Circulatory Support ◽

Assist Device ◽

Ventricular Assist ◽

Cardiac Recovery ◽

Left Ventricular Assist ◽

Bridge To Decision ◽

Va Ecmo

Background: In cardiogenic shock refractory to medical treatment, choosing and changing mechanical circulatory support to stabilize hemodynamics until cardiac recovery or next treatment is a strategic cornerstone for improving the outcome. We aimed to clarify the differences in treatment course and outcome between Impella 5.0 and extracorporeal left ventricular assist device (eLVAD) in patients with cardiogenic shock refractory to medical therapy or other mechanical circulatory support. Methods: We performed a retrospective medical record review of consecutive patients who were treated with Impella 5.0 or eLVAD as a bridge to decision (BTD) at our medical center from December 2011 to January 2020. Results: A total of 26 patients (median age 40 years, 16 males) were analyzed. Of seven patients managed with Impella 5.0, one patients used Impella CP and four patients used peripheral veno-arterial extracorporeal membrane oxygenation (VA-ECMO) before Impella 5.0 implantation. On the other hand, of 19 patients managed with eLVAD, 11 patients used VA-ECMO before eLVAD implantation. In patients managed with Impella 5.0, Impella 5.0 was removed successfully in two patients (29%) and four patients (71%) underwent the operation for durable LVAD. In patients managed with eLVAD, eLVAD was successfully removed in three patients (16%), nine patients (47%) required durable LVAD, and seven patients (37%) died during eLVAD management. The period between implantation of Impella 5.0 or eLVAD to durable LVAD surgery was significantly shorter with Impella 5.0 (58 [38 - 95] vs. 235 [126 - 318] days, p=0.001). During durable LVAD implantation, cardiopulmonary bypass time was significantly shorter and a significantly smaller amount of red blood cells transfusion was required with Impella 5.0 (149 [125 - 182] vs. 192 [170 - 250] minutes, p=0.042; 7.0 [5.0 - 9.5] vs. 15.0 [10.0- 2.0] units, p=0.019, respectively). There were 4 massive stroke events in eLVAD, but no massive stroke events in Impella 5.0. In Impella 5.0. Conclusions: Impella 5.0 facilitates smoother management as a BTD and reduces surgical invasiveness during durable LVAD implantation. Impella 5.0 would be a more effective option for success to cardiac recovery or next therapy than eLVAD.

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IMPELLA® or Extracorporeal Membrane Oxygenation for Left Ventricular Dominant Refractory Cardiogenic Shock

Journal of Clinical Medicine ◽

10.3390/jcm10040759 ◽

2021 ◽

Vol 10 (4) ◽

pp. 759

Author(s):

Guillaume Schurtz ◽

Natacha Rousse ◽

Ouriel Saura ◽

Vincent Balmette ◽

Flavien Vincent ◽

...

Keyword(s):

Extracorporeal Membrane Oxygenation ◽

Cardiogenic Shock ◽

Mechanical Circulatory Support ◽

Left Ventricular ◽

Circulatory Support ◽

Membrane Oxygenation ◽

Refractory Cardiogenic Shock ◽

Significant Difference ◽

Va Ecmo ◽

Unadjusted Analysis

Mechanical circulatory support (MCS) devices are effective tools in managing refractory cardiogenic shock (CS). Data comparing veno-arterial extracorporeal membrane oxygenation (VA-ECMO) and IMPELLA® are however scarce. We aimed to assess outcomes of patients implanted with these two devices and eligible to both systems. From 2004 to 2020, we retrospectively analyzed 128 patients who underwent VA-ECMO or IMPELLA® in our institution for refractory left ventricle (LV) dominant CS. All patients were eligible to both systems: 97 patients were first implanted with VA-ECMO and 31 with IMPELLA®. The primary endpoint was 30-day all-cause death. VA-ECMO patients were younger (52 vs. 59.4, p = 0.006) and had a higher lactate level at baseline than those in the IMPELLA® group (6.84 vs. 3.03 mmol/L, p < 0.001). Duration of MCS was similar between groups (9.4 days vs. 6 days in the VA-ECMO and IMPELLA® groups respectively, p = 0.077). In unadjusted analysis, no significant difference was observed between groups in 30-day mortality: 43.3% vs. 58.1% in the VA-ECMO and IMPELLA® groups, respectively (p = 0.152). After adjustment, VA-ECMO was associated with a significant reduction in 30-day mortality (HR = 0.25, p = 0.004). A higher rate of MCS escalation was observed in the IMPELLA® group: 32.3% vs. 10.3% (p = 0.003). In patients eligible to either VA-ECMO or IMPELLA® for LV dominant refractory CS, VA-ECMO was associated with improved survival rate and a lower need for escalation.

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Mechanical circulatory-support and intravascular lithotripsy in high-risk patients undergoing PCI and TAVR: a case series

European Heart Journal - Case Reports ◽

10.1093/ehjcr/ytab498 ◽

2021 ◽

Author(s):

Alfredo Marchese ◽

Giuseppe Tarantini ◽

Antonio Tito ◽

Vito Margari ◽

Fabrizio Resta ◽

...

Keyword(s):

High Risk ◽

Mechanical Circulatory Support ◽

Case Series ◽

Left Ventricular ◽

Circulatory Support ◽

Transcatheter Aortic Valve ◽

Clinical Scenarios ◽

Risk Patients ◽

Coronary Lesions ◽

Va Ecmo

Abstract Background Patients undergoing transcatheter aortic-valve replacement (TAVR) usually have multiple comorbidities, such as severely impaired left-ventricular function (LVF) and heavily calcified coronary lesions. When they undergo pre-TAVR high-risk percutaneous coronary interventions (HR-PCIs) for severely calcified left-main (LM) lesions, potential life-threatening intra-procedural complications associated with the different techniques available to treat calcified lesions can arise. In this setting, mechanical circulatory support (MCS) proves its usefulness. However, the choice of device can be troublesome. Case summary We report two clinical scenarios of intravascular lithotripsy (IVL) for the treatment of heavily calcified LM coronary lesions, wherein peripheral veno-arterial extracorporeal-membrane oxygenation (VA-ECMO), alone or combined with an intra-aortic balloon pump (IABP), were used as an upfront strategy to support the procedure. The use of these techniques was particularly effective during multi-vessel HR-PCIs and TAVR, and no complications occurred, which suggested their safety. Discussion These cases provide multiple insights into the strategy of using IVL + VA-ECMO, alone or with IABP, to treat heavily calcified LM coronary lesions in patients with severely compromised LVF undergoing TAVR. IVL safely and effectively overcame shortcomings related to other plaque ablation techniques, and VA-ECMO proved to be effective when facing the combination of high-risk coronary and valve interventions.

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A Long Way Home. Biventricular Impella®, VA-ECMO and Extracorporeal LVAD as Bridge to a Permanent LVAD in Severe Ischemic Cardiogenic Shock: A Case Report

10.21203/rs.3.rs-78251/v1 ◽

2020 ◽

Author(s):

Monika Sadlonova ◽

Birgit Gerecke ◽

Aschraf El-Essawi ◽

Lars-Olav Harnisch ◽

Onnen Moerer ◽

...

Keyword(s):

Heart Failure ◽

Coronary Artery ◽

Cardiogenic Shock ◽

Mechanical Circulatory Support ◽

Life Support ◽

Extracorporeal Life Support ◽

Left Ventricular ◽

Circulatory Support ◽

Team Approach ◽

Va Ecmo

Abstract Background: A severe cardiogenic shock can present with clinical complications such as arrhythmias, ischemia and organ failure and even today is associated with a high mortality. Extracorporeal life support (ECLS) by veno-arterial extracorporeal membrane oxygenation (VA-ECMO), Impella® and other mechanical circulatory support systems can reduce the acute circulatory failure. Case presentation: We present the case of a 38-year-old woman with an acute heart failure due to a coronary artery disease who underwent emergency coronary artery bypass grafting and intraoperative implantation of a VA-ECMO. Over the next 4 months, a multidisciplinary team-approach bridged the patient using first a left ventricular (LV) support system (Impella), then additionally a right ventricular (RV) Impella and finally a temporary paracorporeal continuous flow left ventricular support (Rotaflow). Following a promising neurological recovery, a long-term left ventricular assist device (LVAD) was implanted in a bride to transplant (BTT) concept. Conclusions: The addition of LV Impella and RV support by Impella (BiPELLA) on top of VA-ECMO may support survival of patients with refractory cardiogenic shock. In complex biventricular heart failure, an expert center must be able to provide an early multi-modular intervention with elaborated mechanical circulatory support due to a multidisciplinary expertise.

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Venoarterial Extracorporeal Membrane Oxygenation as Mechanical Circulatory Support in Adult Septic Shock: A Systematic Review and Meta-Analysis with Individual Participant Data Meta-Regression Analysis.

10.21203/rs.3.rs-507866/v1 ◽

2021 ◽

Author(s):

Ryan Ruiyang Ling ◽

Kollengode Ramanathan ◽

Wynne Hsing Poon ◽

Chuen Seng Tan ◽

Nicolas Brechot ◽

...

Keyword(s):

Septic Shock ◽

Extracorporeal Membrane Oxygenation ◽

Mechanical Circulatory Support ◽

Meta Analysis ◽

Left Ventricular ◽

Adult Patients ◽

Circulatory Support ◽

Venoarterial Extracorporeal Membrane Oxygenation ◽

Refractory Septic Shock ◽

Va Ecmo

Abstract Background: While recommended by international societal guidelines in the paediatric population, the use of venoarterial extracorporeal membrane oxygenation (VA-ECMO) as mechanical circulatory support for refractory septic shock in adults is controversial. We aimed to characterise the outcomes of adults with septic shock requiring VA-ECMO, and identify factors associated with survival.Methods: We searched Pubmed, Embase, Scopus and Cochrane databases from inception until 1st April 2021, and included all relevant publications reporting on >5 adult patients requiring VA-ECMO for septic shock. Study quality and certainty in evidence were assessed using the appropriate Joanna Briggs Institute checklist, and the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) approach respectively. The primary outcome was survival to hospital discharge, and secondary outcomes included intensive care unit length of stay, duration of ECMO support, complications while on ECMO, and sources of sepsis. Random-effects meta-analysis (DerSimonian and Laird) were conducted. Data synthesis: We included 14 observational studies with 468 patients in the meta-analysis. Pooled survival was 36.4% (95% confidence interval [CI] :23.6%-50.1%). Survival among patients with left ventricular ejection fraction (LVEF) <20% (62.0%, 95%CI: 51.6%-72.0%) was significantly higher than those with LVEF>35% (32.1%, 95%CI: 8.69%-60.7%, p=0.05). Survival reported in studies from Asia (19.5%, 95%CI: 13.0%-26.8%) was notably lower than those from Europe (61.0%, 95%CI: 48.4%-73.0%) and North America (45.5%, 95%CI: 16.7%-75.8%). Extracorporeal cardiopulmonary resuscitation was associated with reduced chances of survival (Risk ratio: 0.403, 95%CI: 0.197-0.826, p=0.01). GRADE assessment indicated high certainty of evidence for pooled survival.Conclusions: When treated with VA-ECMO, the majority of patients with septic shock and severe sepsis-induced myocardial depression survive. However, VA ECMO has poor outcomes in adults with septic shock but without severe left ventricular depression. VA-ECMO may be a viable treatment option in carefully selected adult patients with refractory septic shock.

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Outcomes and risk factors of mechanical circulatory support by peripheral venoarterial extracorporeal membrane oxygenation in heart transplant candidates needing urgent heart transplantation

Russian Journal of Transplantology and Artificial Organs ◽

10.15825/1995-1191-2017-4-54-60 ◽

2018 ◽

Vol 19 (4) ◽

pp. 54-60 ◽

Cited By ~ 1

Author(s):

V. N. Poptsov ◽

V. M. Zakharevich ◽

E. A. Spirina ◽

S. G. Uhrenkov ◽

A. A. Dogonasheva ◽

...

Keyword(s):

Risk Factors ◽

Left Atrium ◽

Heart Transplant ◽

Mechanical Circulatory Support ◽

Left Ventricular ◽

Circulatory Support ◽

Left Heart ◽

Lethal Outcome ◽

Transplant Candidates ◽

Va Ecmo

Introduction Peripheral veno-arterial extracorporeal membrane oxygenation (VA ECMO) is one of the most frequently used methods of temporary mechanical circulatory support (MCS) at patients with life-threatening circulatory derangement.Aim: to evaluate the effectiveness and risk factors of peripheral VA ECMO in patients waiting of urgent heart transplantation (HT). Materials and methods. The study included 149 (129 (86.6%) men and 20 (13.4%) women, age 12 to 72 (43.0 ± 1.2) years) heart transplant candidates who in the period 01.01.2011–31.12.2016 were supported by peripheral VA ECMO. These patients were 21.1% of the total waiting list (n = 706) of our institute at the same period. Indication for MCS by VA ECMO was advanced heart failure corresponding to I or II level of INTERMACS classiﬁ cation.Results. 135 (90.6%) from 149 patients were successfully supported to HT. 14 (9.4%) deed following MCS. Before of VA ECMO these patients (n = 14) had more severe (p < 0.05) hemodynamic disorders, organ dysfunction, electrolyte and metabolic disorders compared to patients TC successfully supported to HT. Left atrium (n = 24)/left ventricle drainage (n = 8) was performed for volume decompression of left heart (n = 32 (21.5%)). In a single-factor analysis, statistically signiﬁ cant pre VA ECMO risk factors for the lethal outcome were: creatinine ≥ 140 mmol/l, urea ≥ 15 mmol/l, total bilirubin ≥ 80 μmol/l, ALT ≥ 300 U/l, AST ≥ 300 U/l, INR ≥ 3.0, procalcitonin ≥ 3.0 ng/ml, preexisting left ventricular thrombosis complicated thromboembolic stroke with brain death following VA ECMO (n = 3). Statistically signiﬁ cant factors for the lethal outcome following MCS were: transthoracic left ventricle drainage (n = 8) compared to transcutaneous transfemoral transseptal left atrium drainage (n = 24) for volume decompression of left heart; hemolysis ≥ 300 mg%. Conclusion. VA ECMO is high efﬁ ciency method of temporary MCS in 90.6% heart transplant candidates needed at urgent HT. VA ECMO must be begin before development of potential lethal multiorgan and septic complications. Preexisting left ventricular thrombosis increase risk of lethal thromboembolic brain injury following VA ECMO. Patients with transcutaneous transfemoral transseptal left atrium drainage for left heart volume decompression had better outcome following MCS by VA ECMO.

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COVID-19 era: time for temporary mechanical circulatory support?

European Heart Journal Acute Cardiovascular Care ◽

10.1093/ehjacc/zuab020.167 ◽

2021 ◽

Vol 10 (Supplement_1) ◽

Author(s):

M Alonso Fernandez De Gatta ◽

A Diego Nieto ◽

S Merchan Gomez ◽

M Gonzalez Cebrian ◽

I Toranzo Nieto ◽

...

Keyword(s):

Cardiac Arrest ◽

Cardiogenic Shock ◽

Mechanical Circulatory Support ◽

Left Ventricular ◽

Public Institution ◽

Left Ventricular Ejection ◽

Circulatory Support ◽

Short Term ◽

Ventricular Ejection Fraction ◽

Va Ecmo

Abstract Funding Acknowledgements Type of funding sources: Public Institution(s). Main funding source(s): Instituto de Salud Carlos III in Spain (Co-funded by European Social Fund "Investing in your future"). INTRODUCTION The Coronavirus disease 19 (COVID-19) pandemic has impacted clinical practice with important changes in the most affected areas, resulting in increased mortality from heart disease (myocardial infarction). The feasibility of continuing a temporary mechanical circulatory support (MCS) program is unknown. PURPOSE Our objective was to analyze the survival of patients requiring short-term MCS with veno-arterial extracorporeal membrane oxygenation (VA-ECMO) or Impella CP® during the COVID-19 pandemic. METHODS Retrospective study including all VA-ECMO and Impella CP® implants in a referral hospital since March 2020 compared to previous implants results. RESULTS Out of 167 short-term MCS implanted from 2013, 25 (15%) were conducted during the time of COVID-19 pandemic: 19 VA-ECMO and 6 Impella CP® (Table). Compared to preCOVID-19 implants, patients requiring MCS in the COVID era presented more frequently right ventricular dysfunction (p = 0.005) and showed a trend towards older age (p = 0.069) and lower left ventricular ejection fraction (p = 0.063), without other significant differences regarding the baseline situation and implant technique (Table). Encephalopathy was more frequent in the COVID-19 era, with no differences in other complications (Table). Survival at discharge was 43.7% in the pre-COVID era vs 36% during COVID-19 pandemic, without finding statistically significant differences (p = 0.313). CONCLUSION Survival after temporary MCS did not get worse significantly during the COVID-19 pandemic. The possibility of short-term MCS should be maintained for cardiogenic shock and other cases of hemodynamic instability. Comparison MCS before and during COVIDTime of implantP valueTime of implantP valuePre-COVID-192013-Feb 2020 (n = 142)COVID-19 timeMarch 2020-Nov 2020 (n = 25)Pre-COVID-192013-Feb 2020 (n = 142)COVID-19 timeMarch 2020-Nov 2020 (n = 25)Age (years) (mean+ SD)Male (n, %)62 ± 10 108 (76%)66 ± 10 15 (60%)0.069 0.079Support type VA-ECMO (n = 137) Impella CP® (n = 30) Percutaneous implant 118 (83.1%)24 (16.9%) 100 (70.4% 19 (76%) 6 (24%) 20 (80%)0.566 0.536Indication (n,%) Cardiogenic shock Refractory cardiac arrest Electrical storm0.63763 (44.4%)16 (11.3%)9 (6.3%)12 (48%) 4 (16%)2 (8%)Drugs at the implant Noradrenaline Dobutamine Adrenaline 115 (81%)114 (80.3%)51 (35.9%) 21 (84%) 21 (84%) 5 (20%) 0.370 0.312 0.108High-risk PCI Postcardiotomy shock Others17 (12%)36 (25.4%)1 (0.7%)3 (12%)4 (16%) 0 (0%)Time MCS (days)4.8 ± 53.9 ± 40.284 7.23 ± 0.16.8 ± 5 0.2920.495Complications (n,%) Vascular (bleeding, ischemia) Bleeding (minor or major) Critical care infections 35 (24.6%)59 (41.5%)67 (47.2%) 7 (28%) 9 (36%) 9 (36%) 0.096 0.117 0.096pH (mean + SD)lactate (mmol/L) (mean + SD)7.13 ± 16.03 ± 5LVEF (%) (mean + SD)Right ventricle dysfunction (n,%)28.7 ± 16 68 (47.9%)21.9 ± 15 20 (80%)0.063 0.005Ischemic/hemorragic stroke Renal replacement therapy Tracheostomy Encephalopathy9 (6.3%) 36 (25.4%) 23 (16.2%)14 (9.8%)2 (8%) 4 (16%) 5 (20%) 6 (24%)0.220 0.136 0.547 0.023Preimplant cardiac arrest (n,%)Cardiac arrest duration (min) (n,%)68 (47.9%) 28.7 ± 2312 (48%) 29.8 ± 230.364 0.880Survival at discharge (n,%)62 (43.7%)9 (36%)0.313

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