Invited commentary

Abstract

Dr Copeland discloses a financial relationship with SynCardia. Dr Copeland discloses a financial relationship with SynCardia. The authors [1Hoefer D. Ruttmann E. Poelzl G. et al.Outcome evaluation of the bridge to bridge concept in patients with cardiogenic shock.Ann Thorac Surg. 2006; 82: 28-34Abstract Full Text Full Text PDF PubMed Scopus (117) Google Scholar] have made a good case for short term (< 3 days) use of extracorporeal membrane oxygenation (ECMO) in patients with cardiogenic shock. Approximately 50% of the 131 patients survived including 46 being weaned from ECMO, 14 of 28 surviving bridge to a ventricular assist device (3 weaned and 11 transplanted), and 5 being transplanted after 4 days of ECMO support. The ECMO support period gave the authors time to sort out problems of neurologic and other end-organ damage before committing to a plan for recovery, VAD, or transplantation. This care algorithm, although acceptable in Innsbruck where donors seem to be more readily available and the cost of ECMO is reasonable, may not be as applicable in other locations. A wide variety of patient presentations and availability of device types, as well as differing infrastructure for ECMO programs may dictate a spectrum of other approaches. Our program is an example. We have repeatedly used ECMO for cardiac arrests when resuscitation efforts have failed. Then, depending on the presentation (ie, a waiting list patient, a viral syndrome, postpartum, coronary disease, and so forth) and patient condition, we decide whether to go to a more advanced device support within a day (ie, the left ventricular assist device, biventricular assist device, or total artificial heart [TAH]) or whether to continue ECMO with the hope of recovery. The chance of a donor for transplantation within 60 days in our program is small. In cardiogenic shock without cardiac arrest, the cause, general condition, and potential transplant candidacy of a patient often dictates the next move. We would think of ECMO for very short-term reversible conditions, and for others we would be much more likely to use an left ventricular assist device in the more stable patients, and either a biventricular assist device (body surface area < 1.7M2) or a TAH in less stable patients with early onset of multiple organ failure. The recent availability of the tandem heart with transseptal left atrial cannula through the femoral vein to a tiny centrifugal pump to femoral artery perfusion is appealing for left ventricular assist device support for a short time. Post-cardiotomy, we have found ECMO to be associated with bleeding, require constant attention, and have a high cost in terms of man power and blood component therapy. After several hours of failure to wean from cardiopulmonary bypass, we are looking for a device with no immediate requirement for anticoagulation. For the short term the Abiomed BVS 5000 system has been ideal. For the long term we tend to use biventricular assist devices or TAHs. In each of these, anticoagulation may be started after the patient stops bleeding.