Abstract
BackgroundVeno-arterial extracorporeal membrane oxygenation (VA-ECMO) is increasingly adopted for the treatment of cardiogenic shock (CS). However, a marker of successful weaning remains largely unknown. Our hypothesis was that successful weaning is associated with sustained microcirculatory function during ECMO flow reduction. Therefore, we sought to test the usefulness of microcirculatory imaging in the same sublingual spot, using incident dark field (IDF) imaging in assessing successful weaning from VA-ECMO and compare IDF imaging with echocardiographic parameters.MethodsWeaning was performed by decreasing the VA-ECMO flow to 50% (F50) from the baseline. The endpoint of the study was successful VA-ECMO explantation within 48 hours after weaning. The response of sublingual microcirculation to a weaning attempt (WA) was evaluated. Microcirculation was measured in one sublingual area (single spot (ss)) using CytoCam IDF imaging during WA. Total vessel density (TVDss) and perfused vessel density (PVDss) of the sublingual area were evaluated before and during 50% flow reduction (TVDssF50, PVDssF50) after a WA and compared to conventional echocardiographic parameters as indicators of the success or failure of the WA.ResultsPatients (n = 13) aged 49 ± 18 years, who received VA-ECMO for the treatment of refractory CS due to pulmonary embolism (n = 5), post cardiotomy (n = 3), acute coronary syndrome (n = 2), myocarditis (n = 2) and drug intoxication (n = 1), were included. TVDssF50 (21.9 vs 12.9 mm/mm2, p = 0.001), PVDssF50 (19.7 vs 12.4 mm/mm2, p = 0.01) and aortic velocity–time integral (VTI) at 50% flow reduction (VTIF50) were higher in patients successfully weaned vs not successfully weaned. The area under the curve (AUC) was 0.99 vs 0.93 vs 0.85 for TVDssF50 (small vessels) >12.2 mm/mm2, left ventricular ejection fraction (LVEF) >15% and aortic VTI >11 cm. Likewise, the AUC was 0.91 vs 0.93 vs 0.85 for the PVDssF50 (all vessels) >14.8 mm/mm2, LVEF >15% and aortic VTI >11 cm.ConclusionThis study identified sublingual microcirculation as a novel potential marker for identifying successful weaning from VA-ECMO. Sustained values of TVDssF50 and PVDssF50 were found to be specific and sensitive indicators of successful weaning from VA-ECMO as compared to echocardiographic parameters.
Highlights
Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is increasingly adopted for the treatment of cardiogenic shock (CS)
We found that the functional microcirculatory parameters measured sublingually using incident dark field (IDF) imaging (TVDssF50 and PVDssF50) during weaning attempts for patients from VA-ECMO showed essential alterations within 2 minutes and prediction of cardiac recovery after cardiogenic shock
Future clinical and possible crossover studies should be designed in larger study populations undergoing VA-ECMO for monitoring microcirculation to guide weaning attempts
Summary
Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is increasingly adopted for the treatment of cardiogenic shock (CS). A marker of successful weaning remains largely unknown. Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is considered a lifesaving treatment that is increasingly used for the treatment of critically ill patients that have experienced CS [2,3,4]. Current strategies for weaning from VA-ECMO are ongoing, largely unknown and based on empirical evidence [6,7,8]. Most of the current markers of weaning from VA-ECMO are based on echocardiography, such as aortic velocity–time integral (VTI), left ventricular ejection fraction (LVEF), and tissue Doppler lateral mitral annulus peak systolic velocity (TDSa) [9]. Performing high-quality echocardiography in critically ill patients requires specialized training and is relatively costly [10]
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