Abstract
Venoarterial extracorporeal membrane oxygenation (VA-ECMO) provides temporary cardiac and respiratory support and has emerged as an established salvage intervention for patients with hemodynamic compromise or shock. It is thereby used as a bridge to recovery, bridge to permanent ventricular assist devices, bridge to transplantation, or bridge to decision. However, weaning from VA-ECMO differs between centers, and information about standardized weaning protocols are rare. Given the high mortality of patients undergoing VA-ECMO treatment, it is all the more important to answer the many questions still remaining unresolved in this field Standardized algorithms are recommended to optimize the weaning process and determine whether the VA-ECMO can be safely removed. Successful weaning as a multifactorial process requires sufficient recovery of myocardial and end-organ function. The patient should be considered hemodynamically stable, although left ventricular function often remains impaired during and after weaning. Echocardiographic and invasive hemodynamic monitoring seem to be indispensable when evaluating biventricular recovery and in determining whether the VA-ECMO can be weaned successfully or not, whereas cardiac biomarkers may not be useful in stratifying those who will recover. This review summarizes the strategies of weaning of VA-ECMO and discusses predictors of successful and poor weaning outcome.
Highlights
Technological improvements during the last decade have enabled a dramatic increase in the utilization of temporary extracorporeal cardiac and respiratory support systems [1]
The main indications are cardiogenic shock, cardiac arrest, refractory ventricular tachycardia, right ventricular (RV) failure during left ventricular assist device (LVAD) support, failure to wean off cardiopulmonary bypass, extended in-hospital resuscitation (extracorporeal cardiopulmonary resuscitation), and prehospital use of veno-arterial extracorporeal membrane oxygenation (VA-ECMO) [2,3]
For patients treated with VA-ECMO for postcardiotomy shock, age, gender, diabetes, preoperative renal insufficiency, obesity, serum butyrylcholinesterase, mean lactate concentration, lactate clearance, and logistic EuroSCORE are factors reported to be associated with poor outcome [25,31,32,33]
Summary
Technological improvements during the last decade have enabled a dramatic increase in the utilization of temporary extracorporeal cardiac and respiratory support systems [1]. The Extracorporeal Life Support Organization Registry (ELSO) reported overall survival at hospital discharge of 41% for adult patients on VA-ECMO [9] In the latter registry, data on outcome are limited to observational studies and vary significantly depending on underlying indication. Risk scores like the Survival After Veno-arterial-ECMO score (SAVE) or the Prediction of Cardiogenic Shock Outcome for AMI Patients Salvaged by VA-ECMO score (ENCOURAGE) have been developed in order to better evaluate the utility of VA-ECMO support and to improve the decision-making process. These are based on pre-ECMO risk factors independently associated with poor outcomes. The related studies revealed older age, female sex, and higher body mass index as well as markers of illness severity including elevated serum lactate levels, renal, hepatic, or central nervous system dysfunction, longer duration of mechanical ventilation, and reduced prothrombin activity as independent predictors of poor outcome [13,19]
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