Stroke Complications in Patients Requiring Durable VAD Systems after VA-ECMO Support

Background and Objectives: Over the past decade, veno-arterial extracorporeal membrane oxygenation (VA-ECMO) has developed into a mainstream treatment for refractory cardiogenic shock (CS) to maximal conservative management. Successful weaning of VA-ECMO may not be possible, and bridging with further mechanical circulatory support (MCS), such as urgent implantation of a left ventricular assist device (LVAD), may represent the only means to sustain the patient haemodynamically. In the recovery phase, many survivors are not suitably prepared physically or psychologically for the novel issues encountered during daily life with an LVAD. Materials and Methods: A retrospective analysis of our institutional database between 2012 and 2019 was performed to identify patients treated with VA-ECMO for CS who underwent urgent LVAD implantation whilst on MCS. Post-cardiotomy cases were excluded. QoL was assessed prospectively during a routine follow-up visit using the EuroQol-5 dimensions-5 level (EQ-5D-5L) and the Patient Health Questionnaire (PHQ-9) surveys. Results: Among 126 in-hospital survivors of VA-ECMO therapy due to cardiogenic shock without prior cardiac surgery, 31 (24.6%) urgent LVAD recipients were identified. In 11 (36.7%) cases, cardiopulmonary resuscitation (CPR) was performed (median 10, range 1–60 min) before initiation of VA-ECMO, and in 5 (16.7%) cases, MCS was established under CPR. Mean age at LVAD implantation was 51.7 (+/−14) years and surgery was performed after a mean 12.1 (+/−8) days of VA-ECMO support. During follow-up of 46.9 (+/−25.5) months, there were 10 deaths after 20.4 (+/−12.1) months of LVAD support. Analysis of QoL questionnaires returned a mean EQ-5D-5L score of 66% (+/−21) of societal valuation for Germany and a mean PHQ-9 score of 5.7 (+/−5) corresponding to mild depression severity. When compared with 49 elective LVAD recipients without prior VA-ECMO therapy, there was no significant difference in QoL results. Conclusions: Patients requiring urgent LVAD implantation under VA-ECMO support due to CS are associated with comparable quality of life without a significant difference from elective LVAD recipients. Close follow-up is required to oversee patient rehabilitation after successful initial treatment.

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TCT-699 Outcomes of Venoarterial Extracorporeal Membrane Oxygenation (VA-ECMO) Support for Cardiogenic Shock in a large, Tertiary Care Advanced Heart Failure and Transplant Referral Center From 2013-2017

Journal of the American College of Cardiology ◽

10.1016/j.jacc.2018.08.1914 ◽

2018 ◽

Vol 72 (13) ◽

pp. B279-B280

Author(s):

Colin Hirst ◽

Navin Kapur

Keyword(s):

Heart Failure ◽

Extracorporeal Membrane Oxygenation ◽

Cardiogenic Shock ◽

Tertiary Care ◽

Advanced Heart Failure ◽

Ecmo Support ◽

Referral Center ◽

Venoarterial Extracorporeal Membrane Oxygenation ◽

Large Tertiary Care ◽

Va Ecmo

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High Risk PCI and Aortic Valvuloplasty With VA ECMO Support: A Case of Pre-TAVI Hybrid Therapy

CHEST Journal ◽

10.1378/chest.2266928 ◽

2015 ◽

Vol 148 (4) ◽

pp. 843A

Author(s):

Elie Elmann ◽

Pranaychandra Vaidya ◽

Brian Beckord ◽

Thomas Cocke ◽

Gabriele Diluozzo ◽

...

Keyword(s):

High Risk ◽

Ecmo Support ◽

Hybrid Therapy ◽

Aortic Valvuloplasty ◽

Va Ecmo

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ECMO and Right Ventricular Failure: Review of the Literature

Journal of Intensive Care Medicine ◽

10.1177/0885066619900503 ◽

2020 ◽

pp. 088506661990050 ◽

Cited By ~ 2

Author(s):

Christian Grant ◽

Jeremy B. Richards ◽

Michael Frakes ◽

Jason Cohen ◽

Susan R. Wilcox

Keyword(s):

Right Ventricular ◽

Myocardial Function ◽

Clinical Status ◽

Ecmo Support ◽

Circulatory Support ◽

Hypoxemic Respiratory Failure ◽

Acute Hypoxemic Respiratory Failure ◽

Pulmonary Vasodilators ◽

Va Ecmo ◽

Vv Ecmo

Right ventricular (RV) failure is the inability of the RV to maintain sufficient cardiac output in the setting of adequate preload, due to either intrinsic injury to the RV or increased afterload. Medical treatment of RV failure should include optimizing preload, augmenting contractility with vasopressors and inotropes, and considering inhaled pulmonary vasodilators. However, when medical therapies are insufficient, mechanical circulatory support (MCS) is needed to maintain systemic and RV perfusion. The data on MCS for isolated RV failure are limited, but extracorporeal membrane oxygenation (ECMO) appears to be the most efficient and effective modality. For patients with isolated RV failure from acute hypoxemic respiratory failure, veno-venous (VV) ECMO is an appropriate initial configuration, even if the patient is in shock. With primary RV injury or RV failure with concomitant left ventricle (LV) failure, however, venoarterial (VA) ECMO is indicated. Both modalities provide indirect support to the RV by reducing preload, reducing RV wall tension, and delivering oxygenated blood to the coronary circulation. Peripheral cannulation is required in VV-ECMO and is most commonly used in VA-ECMO, allowing for rapid cannulation even in emergencies. Changes in pulsatility on an arterial catheter waveform can indicate changes in clinical status including changes in myocardial function, inadequate preload, worsening RV failure, and excessive VA-ECMO support leading to an elevated LV afterload. Myocardial function may be improved by titration of inotropes or vasodilators, utilization of an Impella or an intra-aortic balloon counterpulsation support devices, or by changes in VA-ECMO support.

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A retrospective cohort analysis of percutaneous versus side-graft perfusion techniques for veno-arterial extracorporeal membrane oxygenation in patients with refractory cardiogenic shock

Perfusion ◽

10.1177/0267659116683792 ◽

2016 ◽

Vol 32 (5) ◽

pp. 363-371 ◽

Cited By ~ 5

Author(s):

Mehmet Cakici ◽

Evren Ozcinar ◽

Cagdas Baran ◽

Ahmet Onat Bermede ◽

Mehmet Cahit Sarıcaoglu ◽

...

Keyword(s):

Extracorporeal Membrane Oxygenation ◽

Cardiogenic Shock ◽

Femoral Artery ◽

Vascular Complications ◽

Ecmo Support ◽

Acute Limb Ischemia ◽

Membrane Oxygenation ◽

Refractory Cardiogenic Shock ◽

Cannulation Site ◽

Va Ecmo

Objectives: This study was designed to compare vascular complications and the outcomes of ultrasound (US)-guided percutaneous cannulation with distal perfusion catheter (PC-DP) and arterial side-graft perfusion (SGP) techniques in patients who require veno-arterial extracorporeal membrane oxygenation (VA-ECMO) support for refractory cardiogenic shock (RCS). Methods: We conducted a retrospective, observational cohort study of consequtive patients with RCS treated with VA-ECMO at a single transplant center from March 2010 until August 2015. Overall, 148 patients underwent VA-ECMO for RCS (99 men, aged 56.6 ± 12.0 years; BSA, 1.85 ± 0.19). Patients were categorized based on VA-ECMO perfusion technique into PC-DP via femoral artery and SGP via axillary/femoral artery groups. Results: The median duration of VA-ECMO support was 5 days (range, 8 hours–80 days). Hospital mortality (PC-DP group, 54.7%; SGP group, 64.4%; p=0.23) and overall ECMO survival (PC-DP group, 36.9%; SGP group, 32.2%; p=0.47) was similar between the groups. There were no significant between-group differences in the rate of acute limb ischemia (PC-DP group, 4/75, 5.3%; SGP group, 2/73, 2.7%; p=0.68). However, the rate of surgical/cannulation site bleeding (PC-DP, 9/75 (12%) vs SGP, 18/73 (24.7%), p=0.05) and hyperperfusion syndrome (PC-DP, 2/75 (2.7%) vs SGP, 22/73 (30.1%),p=0.001) were higher in the SGP group than in the PC-DP group. Conclusions: We observed no significant difference in major vascular complications or survival between patients who underwent the PC-DP technique and those who underwent arterial SGP.

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TCTAP C-163 Percutaneous Coronary Intervention in Cardiogenic Shock Under VA-ECMO Support

Journal of the American College of Cardiology ◽

10.1016/j.jacc.2016.03.565 ◽

2016 ◽

Vol 67 (16) ◽

pp. S289-S291

Author(s):

Jin Sup Park ◽

Hye Won Lee ◽

Jun-Hyok Oh ◽

Han Cheol Lee ◽

Kwang Soo Cha ◽

...

Keyword(s):

Percutaneous Coronary Intervention ◽

Cardiogenic Shock ◽

Coronary Intervention ◽

Ecmo Support ◽

Percutaneous Coronary ◽

Va Ecmo

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Venoarterial extracorporeal membrane oxygenation for cardiogenic shock: a retrospective analysis based on the etiology of shock

The VAD Journal ◽

10.14434/vad.v3i0.27974 ◽

2017 ◽

Author(s):

Andrew Burchett ◽

Thomas Tribble ◽

Richard Charnigo ◽

Susan Smyth ◽

Maya Guglin

Keyword(s):

Pulmonary Embolism ◽

Cardiogenic Shock ◽

Retrospective Analysis ◽

Hospital Discharge ◽

Reference Group ◽

Ecmo Support ◽

Uniform System ◽

Venoarterial Extracorporeal Membrane Oxygenation ◽

Significant Difference ◽

Va Ecmo

Background We performed a retrospective analysis to evaluate the efficacy of VA-ECMO support in cardiogenic shock based on various etiologies. Methods We retrospectively analyzed 99 patients supported with VA-ECMO from January 1, 2012 to January 1, 2015. Outcomes included survival to discontinuation of VA-ECMO support and survival to hospital discharge. The etiologies of cardiogenic shock included cardiac arrest (CPR), acute myocardial infarction (AMI), decompensated congestive heart failure (CHF), pulmonary embolism (PE), right ventricular failure (RVF) not secondary to an acute pulmonary embolism, and post-cardiotomy syndrome (PCS). The PCS group was used as a reference group; odds ratios were estimated and Fisher’s exact tests were performed to compare each other group to the reference. Results Patients supported with VA-ECMO due to PE and CHF had better survival to hospital discharge (83.3% and 54.2%, with p = 0.003 and p = 0.011, respectively) versus the PCS group (7.7%). The PE, CHF, and AMI groups had statistically improved survival to VA-ECMO discontinuation. There was no statistically significant difference in survival to VA-ECMO discontinuation or hospital discharge in four subgroup analyses. Conclusions Patients supported with VA-ECMO in cardiogenic shock due to PE or CHF demonstrated increased rates of survival to hospital discharge when compared to the PCS group. This study also highlights the need for a more uniform system of categorizing etiologies of cardiogenic shock.

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