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

Abstract Background The use of peripheral veno-arterial extracorporeal life support (V-A ECLS) as a mechanical circulatory support in cardiogenic shock has increased dramatically over the last years. However, increased afterload may jeopardize left ventricle (LV) recovery and cause blood stasis and pulmonary edema. Therefore, several LV unloading techniques have been developed and used with limited understanding of the actual difference among them. The aim of the present study was to compare a trans-aortic suction device (Impella) and pulmonary artery (PA) drainage, for LV unloading and V-A ECLS management as well as efficacy in a porcine cardiogenic shock (CS) model Methods A dedicated CS model compared included twelve female swine (21± 1,8-weeks old and weighing 54,3 ± 4,6 kg) supported with V-A ECLS and randomized to Impella or PA-related LV drainage. LV unloading and end-organ perfusion were evaluated through the pulmonary artery catheter and the LV pressure/volume analysis. All the variables were collected at baseline, profound CS, V-A ECLS support with maximum flow and when Impella or PA cannula run on top. Results CS was successfully induced in all twelve animals. Impella resulted in a marked drop of LVEDV compared to a slight decrease in the PA cannula group, resulting in an overall stroke work (SW) and Pressure-Volume Area (PVA) reductions with both techniques. However, SW reduction was significant in the Impella CP group (VA ECMO 3998.82027.6 mmHg x mL vs VAECMO + Impella 1796.9±1033.9 mmHg x ml, p value 0,016), leading to a more consistent PVA reduction (Impella reduction 34,7% vs PA cannula reduction 9,7%) In terms of end organ perfusion, central and mixed O 2 saturation improved with V-A ECLS, and subsequently, remaining unchanged with either Impella or PA cannula as unloading strategy Conclusions Trans-aortic suction and PA drainage provided effective LV unloading during V-A ECLS while maintaining adequate end-organ perfusion. Trans-aortic suction device provides a greater LV unloading effect and reduces more effectively the total LV stroke work.

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Flow manipulation and the association with myocardial contractility during extracorporeal life support (FLAME)

European Heart Journal Acute Cardiovascular Care ◽

10.1093/ehjacc/zuab020.030 ◽

2021 ◽

Vol 10 (Supplement_1) ◽

Author(s):

SKT Ma ◽

WC Sin ◽

CW Ngai ◽

ASK Wong ◽

WM Chan ◽

...

Keyword(s):

Blood Flow ◽

Cardiogenic Shock ◽

Myocardial Contractility ◽

Life Support ◽

Extracorporeal Life Support ◽

Left Ventricular ◽

Left Ventricular Ejection ◽

Ventricular Contractility ◽

Left Ventricular Contractility ◽

Extracorporeal Blood

Abstract Funding Acknowledgements Type of funding sources: None. Background Veno-arterial extracorporeal membrane oxygenation (V-A ECMO) is an advanced technique in extracorporeal life support (ECLS) used to support extreme circulatory failure including patients with cardiac arrest and cardiogenic shock refractory to conventional support. It is a long-standing belief that peripheral V-A ECMO poses increased afterload to the inured heart, but conventional echocardiographic measurements are often insensitive in detecting subtle changes in loading conditions. Purpose This study aimed to evaluate the effects of varying blood flow during peripheral V-A ECMO on intrinsic myocardial contractility, using detailed echocardiographic assessment including speckle tracking echocardiography (STE). Methods Adult patients with acute cardiogenic shock who were supported by peripheral V-A ECMO from April 2019 to September 2020 were recruited. Serial hemodynamic and cardiac performance parameters were measured by transthoracic echocardiogram (TTE) within 48 hours after implementation of V-A ECMO, at different levels of extracorporeal blood flow – 100%, 120% and 50% of target blood flow (TBF). Results A total of 30 patients were included. 22 (71%) were male, and the mean (SD) age was 54 (13) years. The major indications for V-A ECMO were myocardial infarction (19, 63% patients), and myocarditis (5, 17%). With a decrease in extracorporeal blood flow from 100% to 50% of TBF, mean arterial pressure (MAP) dropped from 76+/-3 to 64+/-3mmHg (p <0.001), and cardiac index (CI) increased from 0.89+/-0.13 to 1.27+/-0.18L/min/m2 (p < 0.001). All indices of left ventricular contractility improved at a lower extracorporeal blood flow: the myocardial contractility measured by global longitudinal peak systolic strain (GLPSS) improved from -3+/-0.7% to -5+/-0.8% (p < 0.001); left ventricular ejection fraction (LVEF) increased from 21.5+/-2.6% to 30.9+/-2.7% (p < 0.001) and 19.7+/-3.1% to 28.4+/-3.2% (p < 0.001) by biplane and linear methods, respectively; left ventricular index of myocardial performance (LIMP) improved from 1.51+/-0.12 to 1.03+/-0.09 (p < 0.001). Similar findings were reproduced when comparing left ventricular contractility at extracorporeal blood flows of 120% and 50% of TBF. Conclusions The ECMO blood flow rate in peripheral V-A ECMO is inversely related to myocardial contractility, and is quantifiable by myocardial strain measured by STE.

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Inverted takotsubo syndrome complicated with cardiogenic shock requiring veno-arterial extracorporeal membrane oxygenation in a patient with bilateral pheochromocytoma: a case report

European Heart Journal - Case Reports ◽

10.1093/ehjcr/ytaa055 ◽

2020 ◽

Vol 4 (2) ◽

pp. 1-5

Author(s):

Bebiana Manuela Monteiro Faria ◽

João Português ◽

Roberto Roncon-Albuquerque Jr ◽

Rodrigo Pimentel

Keyword(s):

Extracorporeal Membrane Oxygenation ◽

Cardiogenic Shock ◽

Life Support ◽

Extracorporeal Life Support ◽

Left Ventricular ◽

Circulatory Support ◽

Lv Function ◽

Takotsubo Syndrome ◽

Membrane Oxygenation ◽

Lv Dysfunction

Abstract Background Takotsubo syndrome (TS) is characterized by a transient left ventricular (LV) dysfunction and rarely presents with cardiogenic shock (CS). Inverted TS (ITS) is a rare entity associated with the presence of a pheochromocytoma. Case summary We present a case of a young woman was admitted to the emergency department due to intense headache, chest discomfort, palpitations, and breathlessness. An ITS secondary to a pheochromocytoma crisis presenting with CS was diagnosed. The patient was managed with veno-arterial extracorporeal membrane oxygenation, until recovery of LV function. On the 35th day of hospitalization, open bilateral adrenalectomy was performed. Discussion Takotsubo syndrome patients presenting with CS are challenging and clinicians should be aware of underlying causes. Specific triggers such as pheochromocytoma should systematically be considered particularly if ITS was presented. Extracorporeal life support devices could provide temporary mechanical circulatory support in patients with TS on refractory CS and help to manage complex cases with TS due to pheochromocytoma.

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Multiple Organ Failure and Refractory Cardiogenic Shock due to Venlafaxine Intoxication, Successfully Treated with Veno-Arterial Extracorporeal Life Support

10.26420/austincritcarecaserep/2021.1021 ◽

2021 ◽

Vol 5 (1) ◽

Author(s):

Painvin B ◽

◽

Le Balc’h P ◽

Gicquel T ◽

Camus C ◽

...

Keyword(s):

Cardiogenic Shock ◽

Multiple Organ Failure ◽

Organ Failure ◽

Life Support ◽

Extracorporeal Life Support ◽

Multiple Organ ◽

Left Ventricular ◽

Left Ventricular Ejection ◽

Prolonged Release ◽

Refractory Cardiogenic Shock

Venlafaxine has critical side effects from arrhythmias to cardiogenic shock after toxic dose ingestion. We report a case of venlafaxine intoxication with Multiple Organ Failure (MOF) treated with Veno-Arterial Extracorporeal Life Support (VA-ECLS). A 60-year old male with a history of chronic depression ingested 72 tablets of prolonged-release venlafaxine hydrochloride 75 mg (total 5400 mg). Initial EKG showed broadened QRS complexes and Transthoracic Echocardiography (TTE) revealed diffuse ventricular hypokinesia with Left Ventricular Ejection Fraction (LVEF) of 15% for which dobutamine infusion was started. Due to persistent refractory cardiogenic shock and MOF, a Medos® Deltastream® VA-ECLS was surgically implanted in our intensive care unit. On day 1, toxicology analysis found plasma concentrations of venlafaxine 3.2mg/L and its metabolite desmethylvenlafaxine at 0.92 mg/L. At day 6, we performed a weaning trial, enabling ECLS removal. Motion defect of anteroseptal and inferolateral walls was also noticed. EKGs showed a shorten R wave in the anteroseptal territory leading to the potential diagnosis of underlying ischemic cardiomyopathy. The patient was extubated at day-10 and discharged for cardiology unit at day-17. At day-20, cardiac magnetic resonance imaging showed no sign of ischemia and TTE parameters were normalized. This is the first report of refractory cardiogenic shock and MOF due to venlafaxine intoxication treated with VA-ECLS. The main objective of ECLS is to restore cardiac output especially when ventricular failure is refractory to inotropes. Our experience suggests that MOF secondary to refractory cardiogenic shock should quickly prompt the implantation of a VA-ECLS in venlafaxine critical overdose.

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Electrocardiogram-synchronized pulsatile extracorporeal life support preserves left ventricular function and coronary flow in a porcine model of cardiogenic shock

PLoS ONE ◽

10.1371/journal.pone.0196321 ◽

2018 ◽

Vol 13 (4) ◽

pp. e0196321 ◽

Cited By ~ 10

Author(s):

Petr Ostadal ◽

Mikulas Mlcek ◽

Holger Gorhan ◽

Ivo Simundic ◽

Svitlana Strunina ◽

...

Keyword(s):

Cardiogenic Shock ◽

Left Ventricular Function ◽

Ventricular Function ◽

Coronary Flow ◽

Porcine Model ◽

Life Support ◽

Extracorporeal Life Support ◽

Left Ventricular

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Single arterial access ECMELLA: A new concept and step-by-step procedure

10.1510/mmcts.2021.026 ◽

2021 ◽

Keyword(s):

Cardiogenic Shock ◽

New Technologies ◽

Life Support ◽

Extracorporeal Life Support ◽

Left Ventricular ◽

Circulatory Support ◽

Ventricular Assist ◽

Arterial Access ◽

Severe Cardiogenic Shock ◽

Step Procedure

Therapy for cardiogenic shock using temporary mechanical circulatory support has improved significantly in the last decades, providing patients with new technologies for both acute phase stabilization and bridging to long-term therapies. A combination of a venoarterial extracorporeal life support system and the Impella left ventricular assist device (known as the ECMELLA approach) represents an effective therapy for severe cardiogenic shock that achieves high-flow circulatory support with simultaneous left-ventricular unloading. We present the new ECMELLA 2.0 concept, whereby a single arterial access technique is used to treat severe cardiogenic shock. The goal of this technique is to reduce access-related complications and make a bedside staged weaning from mechanical support possible.

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Abstract 19380: Synchronized Pulsatile Extracorporeal Life Support Preserves Left Ventricular Functions in Comparison With Continuous Extracorporeal Flow in Porcine Model of Cardiogenic Shock

Circulation ◽

10.1161/circ.132.suppl_3.19380 ◽

2015 ◽

Vol 132 (suppl_3) ◽

Author(s):

Petr Ostadal ◽

Mikulas Mlcek ◽

Svitlana Strunina ◽

Matej Hrachovina ◽

Andreas Kruger ◽

...

Keyword(s):

Cardiogenic Shock ◽

Pulsatile Flow ◽

Continuous Flow ◽

Life Support ◽

Extracorporeal Life Support ◽

Systolic Pressure ◽

Left Ventricular ◽

Circulatory Support ◽

Lv Function ◽

Myocardial Hypoxia

Introduction: Veno-arterial extracorporeal life support (ECLS) is increasingly used for the therapy of rapidly progressing or severe cardiogenic shock. However, it has been repeatedly shown that increased afterload associated with ECLS significantly deteriorates left ventricular (LV) performance. Recently, new ECG-synchronized pulsatile cardiac assist system was introduced that offers full circulatory support with increased diastolic and decreased systolic extracorporeal flow. The aim of the present study was to compare the parameters of LV function during standard continuous flow ECLS support and ECG-synchronized pulsatile flow ECLS in cardiogenic shock. Methods: Ten female swine (body weight 45 kg) underwent ECLS implantation under general anesthesia and artificial ventilation. Subsequently, acute cardiogenic shock with signs of tissue hypoperfusion was induced by global myocardial hypoxia. Hemodynamic and cardiac performance parameters were then measured at different levels of continuous or pulsatile ECLS flow (ranging from 1 L/min to 4 L/min) using arterial and venous catheters, a pulmonary artery catheter and a LV pressure-volume loop catheter. Results: Myocardial hypoxia resulted in a decline in mean (±SD) cardiac output to 2.3±1.2 L/min, systolic blood pressure to 61±7 mmHg and LV ejection fraction (EF) to 21±7%. Synchronized pulsatile flow was associated with significant reduction of LV end-systolic volume (ESV), increase in LV stroke volume (SV), and higher EF at all ECLS flow levels in comparison with continuous ECLS flow (Figure 1). At selected ECLS flow levels, pulsatile flow reduced also LV end-diastolic pressure (EDP), end-diastolic volume (EDV), and systolic pressure (SP) (Figure 1). Conclusion: Our results indicate that ECG-synchronized pulsatile ECLS flow preserves LV function in comparison with standard continuous-flow ECLS in cardiogenic shock.

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Central extracorporeal life support with left ventricular decompression for the treatment of refractory cardiogenic shock and lung failure

Journal of Cardiothoracic Surgery ◽

10.1186/1749-8090-9-60 ◽

2014 ◽

Vol 9 (1) ◽

Cited By ~ 30

Author(s):

Alexander Weymann ◽

Bastian Schmack ◽

Anton Sabashnikov ◽

Christopher T Bowles ◽

Philipp Raake ◽

...

Keyword(s):

Cardiogenic Shock ◽

Life Support ◽

Extracorporeal Life Support ◽

Left Ventricular ◽

Refractory Cardiogenic Shock ◽

Lung Failure

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Extracorporeal life support with left ventricular decompression—improved survival in severe cardiogenic shock: results from a retrospective study

PeerJ ◽

10.7717/peerj.3813 ◽

2017 ◽

Vol 5 ◽

pp. e3813 ◽

Cited By ~ 9

Author(s):

Bastian Schmack ◽

Philipp Seppelt ◽

Alexander Weymann ◽

Christina Alt ◽

Mina Farag ◽

...

Keyword(s):

Cardiogenic Shock ◽

Life Support ◽

Time Window ◽

Extracorporeal Life Support ◽

Left Ventricular ◽

Critically Ill Patient ◽

Single Centre ◽

Term Survival ◽

Bridge To Transplant ◽

Severe Cardiogenic Shock

ObjectiveExtracorporeal life support (ECLS) is a life-saving procedure used in the treatment of severe cardiogenic shock. Within this retrospective single centre study, we examined our experience in this critically ill patient cohort to assess outcomes and clinical parameters by comparison of ECLS with or without selective left ventricular decompression.MethodsBetween 2004 and 2014 we evaluated 48 adult patients with INTERMACS level 1 heart failure (age 49.7 ± 19.5 years), who received either central ECLS with (n = 20, 41.7%) or ECLS without (n = 28, 58.3%, including 10 peripheral ECLS) integrated left ventricular vent in our retrospective single centre trial.ResultsFollow up was 100% with a mean of 0.83 ± 1.85 years. Bridge to ventricular assist device was feasible in 29.2% (n = 14), bridge to transplant in 10.4% (n = 5) and bridge to recovery in 8.3% (n = 4). Overall 30-day survival was 37.5%, 6-month survival 27.1% and 1-year survival 25.0%. ECLS support with left ventricular decompression showed favourable 30-day survival compared to ECLS without left ventricular decompression (p = 0.034). Thirty-day as well as long-term survival did not differ between the subgroups (central ECLS with vent, ECLS without vent and peripheral ECLS without vent). Multivariate logistic regression adjusted for age and gender revealed ECLS without vent as independent factor influencing 30-day survival.ConclusionECLS is an established therapy for patients in severe cardiogenic shock. Independent of the ECLS approach, 30-day mortality is still high but with superior 30-day survival for patients with ECLS and left ventricular venting. Moreover, by unloading the ventricle, left ventricular decompression may provide an important time window for recovery or further treatment, such as bridge to bridge or bridge to transplant.

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