Veno-arterial extracorporeal membrane oxygenation with concomitant Impella versus concomitant intra-aortic-balloon-pump for cardiogenic shock

Perfusion ◽  
2021 ◽  
pp. 026765912110339
Author(s):  
Shek-yin Au ◽  
Ka-man Fong ◽  
Chun-Fung Sunny Tsang ◽  
Ka-Chun Alan Chan ◽  
Chi Yuen Wong ◽  
...  
Keyword(s):  
Extracorporeal Membrane Oxygenation ◽  
Mechanical Circulatory Support ◽  
Primary Outcome ◽  
Left Ventricular ◽  
Circulatory Support ◽  
Queen Elizabeth Hospital ◽  
Intra Aortic Balloon Pump ◽  
Membrane Oxygenation ◽  
Significant Difference ◽  
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.

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

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.

scholarly journals 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 ◽  
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.

scholarly journals Cardiogenic shock complicating peripartum cardiomyopathy: Importance of early left ventricular unloading and bromocriptine therapy

2018 ◽  
Vol 9 (2) ◽  
pp. 173-182 ◽  
Author(s):  
Jan-Thorben Sieweke ◽  
Tobias Jonathan Pfeffer ◽  
Dominik Berliner ◽  
Tobias König ◽  
Maximiliane Hallbaum ◽  
...  
Keyword(s):  
Extracorporeal Membrane Oxygenation ◽  
Cardiogenic Shock ◽  
Mechanical Circulatory Support ◽  
Axial Flow ◽  
Left Ventricular ◽  
Peripartum Cardiomyopathy ◽  
Circulatory Support ◽  
Membrane Oxygenation ◽  
Refractory Cardiogenic Shock ◽  
Left Ventricular Recovery

Introduction: Acute peripartum cardiomyopathy complicated by cardiogenic shock is a rare but life-threatening disease. A prolactin fragment is considered causal for the pathogenesis of peripartum cardiomyopathy. This analysis sought to investigate the role of early percutaneous mechanical circulatory support with micro-axial flow-pumps and/or veno-arterial extracorporeal membrane oxygenation in combination with the prolactin inhibitor bromocriptine in refractory cardiogenic shock complicating peripartum cardiomyopathy. Methods and results: In this single-centre analysis, five peripartum cardiomyopathy patients with refractory cardiogenic shock received mechanical circulatory support with either Impella CP microaxial pump only ( n=2) or in combination with veno-arterial extracorporeal membrane oxygenation ( n=3) in the setting of biventricular failure. All patients were mechanically ventilated. In all cases mechanical circulatory support was combined with bromocriptine therapy and early administration of levosimendan. All patients survived the acute phase of refractory cardiogenic shock. Mechanical circulatory support using a micro-axial pump allowed to significantly reduce catecholamine dosage. Remarkably, early left ventricular support with micro-axial flow-pumps resulted in myocardial recovery whereas delayed Impella (mechanical circulatory support) implantation was associated with poor left ventricular recovery. Conclusion: Mechanical circulatory support in patients with refractory cardiogenic shock complicating peripartum cardiomyopathy was associated with a 30-day survival of 100% and a favourable outcome. Notably, early left ventricular unloading combined with bromocriptine therapy was associated with left ventricular recovery. Therefore, an immediate transfer to a tertiary hospital experienced in mechanical circulatory support in combination with bromocriptine treatment seems indispensable for successful treatment of peripartum cardiomyopathy complicated by cardiogenic shock.

Venoarterial Extracorporeal Membrane Oxygenation in Cardiogenic Shock: Lifeline of Modern Day CICU

2019 ◽  
pp. 088506661989454
Author(s):  
Aniket S. Rali ◽  
Jonathan Chandler ◽  
Andrew Sauer ◽  
Michael A. Solomon ◽  
Zubair Shah
Keyword(s):  
Extracorporeal Membrane Oxygenation ◽  
Cardiogenic Shock ◽  
Mechanical Circulatory Support ◽  
Treatment Modalities ◽  
Circulatory Support ◽  
Steady Increase ◽  
Membrane Oxygenation ◽  
Cardiopulmonary Support ◽  
Venoarterial Extracorporeal Membrane Oxygenation ◽  
Va Ecmo

Cardiogenic shock (CS) portends an extremely high mortality of nearly 50% during index hospitalization. Prompt diagnoses of CS, its underlying etiology, and efficient implementation of treatment modalities, including mechanical circulatory support (MCS), are critical especially in light of such high predicted mortality. Venoarterial extracorporeal membrane oxygenation (VA-ECMO) provides the most comprehensive cardiopulmonary support in critically ill patients and hence has seen a steady increase in its utilization over the past decade. Hence, a good understanding of VA-ECMO, its role in treatment of CS, especially when compared with other temporary MCS devices, and its complications are vital for any critical care cardiologist. Our review of VA-ECMO aims to provide the same.

scholarly journals Mechanical Circulatory Support to Treat Pulmonary Embolism: Venoarterial Extracorporeal Membrane Oxygenation and Right Ventricular Assist Devices

2020 ◽  
Vol 47 (3) ◽  
pp. 202-206
Author(s):  
Aneil Bhalla ◽  
Robert Attaran
Keyword(s):  
Pulmonary Embolism ◽  
Extracorporeal Membrane Oxygenation ◽  
Right Ventricular ◽  
Mechanical Circulatory Support ◽  
Massive Pulmonary Embolism ◽  
Circulatory Support ◽  
Ventricular Assist ◽  
Membrane Oxygenation ◽  
Venoarterial Extracorporeal Membrane Oxygenation ◽  
Va Ecmo

Mechanical circulatory support may help patients with massive pulmonary embolism who are not candidates for systemic thrombolysis, pulmonary embolectomy, or catheter-directed therapy, or in whom these established interventions have failed. Little published literature covers this topic, which led us to compare outcomes of patients whose massive pulmonary embolism was managed with the use of venoarterial extracorporeal membrane oxygenation (VA-ECMO) or a right ventricular assist device (RVAD). We searched the medical literature from January 1990 through September 2018 for reports of adults hospitalized for massive or high-risk pulmonary embolism complicated by hemodynamic instability, and who underwent VA-ECMO therapy or RVAD placement. Primary outcomes included weaning from mechanical circulatory support and discharge from the hospital. We found 16 reports that included 181 patients (164 VA-ECMO and 17 RVAD). All RVAD recipients were successfully weaned from support, as were 122 (74%) of the VA-ECMO patients. Sixteen (94%) of the RVAD patients were discharged from the hospital, as were 120 (73%) of the VA-ECMO patients. Of note, the 8 RVAD patients who had an Impella RP System were all weaned and discharged. For patients with massive pulmonary embolism who are not candidates for conventional interventions or whose conditions are refractory, mechanical circulatory support in the form of RVAD placement or ECMO may be considered. Larger comparative studies are needed.

scholarly journals Organoprotective Effects of Extracorporeal Membrane Oxygenation and Intra-Aortic Balloon Pump in High-Risk Percutaneous Coronary Intervention in Patients with Acute Coronary Syndrome

2020 ◽  
Vol 16 (1) ◽  
pp. 16-26
Author(s):  
R. A. Kornelyuk ◽  
D. L. Shukevich ◽  
I. E. Vereshchagin ◽  
V. I. Ganyukov
Keyword(s):  
Percutaneous Coronary Intervention ◽  
High Risk ◽  
Extracorporeal Membrane Oxygenation ◽  
Mechanical Circulatory Support ◽  
Coronary Intervention ◽  
Circulatory Support ◽  
Intra Aortic Balloon Pump ◽  
Coronary Syndrome ◽  
Membrane Oxygenation ◽  
Percutaneous Coronary

Purpose of the study: to evaluate the organoprotective effects of veno-arterial extracorporeal membrane oxygenation and intra-aortic balloon pump during high-risk percutaneous coronary intervention in acute coronary syndrome.Materials and methods. Patients required mechanical circulatory support (n=51) were divided into two study groups: patients who received mechanical circulatory support by veno-arterial extracorporeal membrane oxygenation (ECMO) (Group 1, n=29) during high-risk percutaneous coronary intervention, and Group 2 patients who received mechanical circulatory support by intra-aortic balloon pump (IABP) during high-risk percutaneous coronary intervention (Group 2, n=22). The dynamics of instrumental parameters and laboratory markers of organ damage were evaluated by electrocardiography, echocardiography, determining troponin I, creatine phosphokinases and creatinine levels, NGAL, venous blood saturation to compare the organoprotective properties of mechanical circulation support in the intra- and postoperative period.Results. The following values of the parameters were found the next day after the intervention: troponin I — 0.18 (0.1; 2.3) ng/ml in the ECMO group and 1.64 (0.92; 2.36) ng/ml in the IABP group (P=0.045); serum NGAL —139.4 (88.1; 166.7) ng/ml in the ECMO group and 212.3 (102; 279) in the IABP group (P=0.027); renal dysfunction (stages R, I, F according to RIFLE) — 2 (6.8%) observations in the ECMO group and 7 (31.8%) in the IABP group (P=0.021); multiple organ failure (2 or more points according to SOFA) — 3 (10.3%) cases in the ECMO group and 12 (54.5%) in the IABP group (P=0.001).Conclusion. Veno-arterial ECMO in comparison with IABP has a more pronounced organoprotective effect by achieving better hemodynamic stability, which, in turn, prevents hypoxia and the subsequent development of organ dysfunction. In addition, in conditions of veno-arterial ECMO, better completeness and quality of revascularization is ensured, and hospital mortality is also reduced.

Prevention and treatment of pulmonary congestion in patients undergoing venoarterial extracorporeal membrane oxygenation for cardiogenic shock

2020 ◽  
Vol 41 (38) ◽  
pp. 3753-3761 ◽  
Author(s):  
Enzo Lüsebrink ◽  
Mathias Orban ◽  
Danny Kupka ◽  
Clemens Scherer ◽  
Christian Hagl ◽  
...  
Keyword(s):  
Critical Care ◽  
Extracorporeal Membrane Oxygenation ◽  
Cardiogenic Shock ◽  
Left Ventricular ◽  
Ventricular Assist Devices ◽  
Circulatory Support ◽  
Pulmonary Congestion ◽  
Membrane Oxygenation ◽  
Venoarterial Extracorporeal Membrane Oxygenation ◽  
Va Ecmo

Abstract Cardiogenic shock is still a major driver of mortality on intensive care units and complicates ∼10% of acute coronary syndromes with contemporary mortality rates up to 50%. In the meantime, percutaneous circulatory support devices, in particular venoarterial extracorporeal membrane oxygenation (VA-ECMO), have emerged as an established salvage intervention for patients in cardiogenic shock. Venoarterial extracorporeal membrane oxygenation provides temporary circulatory support until other treatments are effective and enables recovery or serves as a bridge to ventricular assist devices, heart transplantation, or decision-making. In this critical care perspective, we provide a concise overview of VA-ECMO utilization in cardiogenic shock, considering rationale, critical care management, as well as weaning aspects. We supplement previous literature by focusing on therapeutic issues related to the vicious circle of retrograde aortic VA-ECMO flow, increased left ventricular (LV) afterload, insufficient LV unloading, and severe pulmonary congestion limiting prognosis in a relevant proportion of patients receiving VA-ECMO treatment. We will outline different modifications in percutaneous mechanical circulatory support to meet this challenge. Besides a strategy of running ECMO at lowest possible flow rates, novel therapeutic options including the combination of VA-ECMO with percutaneous microaxial pumps or implementation of a venoarteriovenous-ECMO configuration based on an additional venous cannula supplying towards pulmonary circulation are most promising among LV unloading and venting strategies. The latter may even combine the advantages of venovenous and venoarterial ECMO therapy, providing potent respiratory and circulatory support at the same time. However, whether VA-ECMO can reduce mortality has to be evaluated in the urgently needed, ongoing prospective randomized studies EURO-SHOCK (NCT03813134), ANCHOR (NCT04184635), and ECLS-SHOCK (NCT03637205). These studies will provide the opportunity to investigate indication, mode, and effect of LV unloading in dedicated sub-analyses. In future, the Heart Teams should aim at conducting a dedicated randomized trial comparing VA-ECMO support with vs. without LV unloading strategies in patients with cardiogenic shock.

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