Venoarterial Extracorporeal Membrane Oxygenation For Cardiogenic Shock Research Articles

The use of venoarterial extracorporeal membrane oxygenation in cardiogenic shock: a narrative review.

Cardiogenic shock (CS) develops in up to 10% of patients with acute myocardial infarction (AMI) and carries a 50% risk of mortality. Despite the paucity of evidence regarding its benefits, venoarterial extracorporeal membrane oxygenation (VA-ECMO) is increasingly used in clinical practice in patients with AMI in CS (AMI-CS). This review aims to provide an in-depth description of the four available randomized controlled trials to date designed to evaluate the benefit of VA-ECMO in patients with AMI-CS. The literature search was conducted on PubMed, Google Scholar, and clinicaltrials.gov to identify the four relevant randomized control trials from years of inception to October 2023. Despite differences in patient selection, nuances in trial conduction, and variability in trial endpoints, all four trials (ECLS-SHOCK I, ECMO-CS, EUROSHOCK, and ECLS-SHOCK) failed to demonstrate a mortality benefit with the use of VA-ECMO in AMI-CS, with high rates of device-related complications. However, the outcome of these trials is nuanced by the limitations of each study that include small sample sizes, challenging patient selection, and high cross-over rates to the intervention group, and lack of use of left ventricular unloading strategies. The presented literature of VA-ECMO in CS does not support its routine use in clinical practice. We have yet to identify which subset of patients would benefit most from this intervention. This review emphasizes the need for designing adequately powered trials to properly assess the role of VA-ECMO in AMI-CS, in order to build evidence for best practices.

Impella vs Veno-arterial extracorporeal membrane oxygenation in cardiogenic shock: a systematic review and meta-analysis of propensity score matched studies

Abstract Funding Acknowledgements Type of funding sources: Private company. Main funding source(s): Abiomed Singapore PTE. Ltd. Background/Introduction Cardiogenic shock is a life-threatening condition associated with multi-organ failure and death. Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is well-established in the management of cardiogenic shock; however, mortality rates have remained relatively consistent over the past two decades. Impella is a transluminal microaxial ventricular assist device that improves haemodynamics by unloading the left ventricle and represents an alternative to VA-ECMO. No randomised controlled trials exist to date comparing Impella versus VA-ECMO given difficulties in recruiting patients due to the acute nature of the condition. Whilst a plethora of non-randomised, comparative studies have been published, many are confounded by underlying differences in baseline disease characteristics. Propensity score matched / adjusted studies may mitigate confounding by accounting for differences in important covariates that impact outcomes. Purpose The objective of this study was to conduct a systematic review and meta-analysis of propensity score matched / adjusted studies to assess the clinical outcomes of Impella versus VA-ECMO in cardiogenic shock patients. Methods A systematic review was undertaken to identify all comparative studies of Impella and VA-ECMO in cardiogenic shock which performed propensity score matching / adjustment of outcomes to account for important covariates. The study limitations were assessed using the GRADE (Grading of Recommendations, Assessment, Development and Evaluations) approach. In-hospital/30-day survival and bleedings requiring transfusion were meta-analysed using the random effects method. Results Six propensity score matched / adjusted studies comparing Impella versus VA-ECMO in cardiogenic shock were included in the meta-analysis. A statistically significant difference in in-hospital/30-day mortality was detected between patients treated with Impella (39.6%) versus VA-ECMO (53.8%) (odds ratio [OR] 95% confidence interval [95% CI]: 0.57 [0.44, 0.74]; p<0.0001). Similarly, Impella (19.9%) was associated with statistically significantly fewer bleeding events requiring transfusion compared with VA-ECMO (28.8%) (OR=0.61 [0.46, 0.80]; p=0.0004). Conclusion(s) This systematic review identified no randomised controlled trials of Impella versus VA-ECMO. The meta-analysis of propensity matched observational trials, represents the highest level of evidence available to date, and suggests that Impella may be associated with increased survival rates and decreased bleeding. Randomised controlled trials are urgently needed to assess cardiac support modalities in cardiogenic shock.

ECMO for drug-refractory electrical storm without a reversible trigger: a retrospective multicentric observational study.

Drug-refractory electrical storm (ES) is a life-threatening medical emergency. We describe the use of venoarterial extracorporeal membrane oxygenation (VA-ECMO) in drug-refractory ES without a reversible trigger, for which specific guideline recommendations are still lacking. Retrospective observational study in four Iberian centres on the indications, treatment, complications, and outcome of drug-refractory ES not associated with acute coronary syndromes, decompensated heart failure, drug toxicity, electrolyte disturbances, endocrine emergencies, concomitant acute illness with fever, or poor compliance with anti-arrhythmic drugs, requiring VA-ECMO for circulatory support. Thirty-four (6%) out of 552 patients with VA-ECMO for cardiogenic shock were included [71% men; 57 (44-62) years], 65% underwent cardiopulmonary resuscitation before VA-ECMO implantation, and 26% during cannulation. Left ventricular unloading during VA-ECMO was used in 8 (24%) patients: 3 (9%) with intraaortic balloon pump, 3 (9%) with LV vent, and 2 (6%) with Impella. Thirty (88%) had structural heart disease and 8 (24%) had an implantable cardioverter-defibrillator. The drug-refractory ES was mostly due to monomorphic ventricular tachycardia (VT) and ventricular fibrillation (VF) (59%), isolated monomorphic VT (26%), polymorphic VT (9%), or VF (6%). Thirty-one (91%) required deep sedation, 44% overdrive pacing, 36% catheter ablation, and 26% acute autonomic modulation. The main complications were nosocomial infection (47%), bleeding (24%), and limb ischaemia (21%). Eighteen (53%) were weaned from VA-ECMO, and 29% had heart transplantation. Twenty-seven (79%) survived to hospital discharge (48 (33-82) days). Non-survivors were older [62 (58-67) vs. 54 (43-58); P<0.01] and had a higher first rhythm disorder-to-ECMO interval [0 (0-2) vs. 2 (1-11) days; P=0.02]. Seven (20%) had rehospitalization during follow-up [29 (12-48) months], with ES recurrence in 6%. VA-ECMO bridged drug-refractory ES without a reversible trigger with a high success rate. This required prolonged hospital stays and coordination between the ECMO centre, the electrophysiology laboratory, and the heart transplant programme.

Increasing sweep gas flow reduces respiratory drive and dyspnea in non-intubated veno-arterial ECMO patients - a pilot study.

Data on assessment and management of dyspnea in patients on veno-arterial extracorporeal membrane oxygenation (VA-ECMO) for cardiogenic shock are lacking. We hypothesized that increasing sweep gas flow through the VA-ECMO oxygenator may decrease dyspnea in non-intubated VA-ECMO patients exhibiting clinically significant dyspnea, with a parallel reduction in respiratory drive. Non-intubated, spontaneously breathing, supine patients on VA-ECMO for cardiogenic shock who presented with a visual analog dyspnea scale (dyspnea-VAS) ≥ 40/100 mm were included. Sweep gas flow was increased up to +6 L/min by three steps of +2 L/min each. Dyspnea was assessed with dyspnea-VAS and Multidimensional Dyspnea Profile. The respiratory drive was assessed by the electromyographic activity of the alae nasi and parasternal muscles. We included 21 patients. On inclusion, median dyspnea-VAS was 50 ([interquartile range] 45-60) mm and sweep gas flow was 1.0 L/min (0.5-2.0). An increase in sweep gas flow significantly decreased dyspnea-VAS (50[45-60] at baseline vs 20[10-30] at 6L/min; p<0.001). The decrease in dyspnea was greater for the sensory component of dyspnea (-50%[43-75]) than for the affective and emotional components (-17%[0-25] and -12%[0-17], p<0.001). An increase in sweep gas flow significantly decreased electromyographic activity of the alae nasi and parasternal muscles (-23%[36-10] and -20[41-0], p<0.001). There was a significant correlation between the sweep gas flow and the dyspnea-VAS (r=-0.91 95%CI[-0.94, -0.87]), between the respiratory drive and the sensory component of dyspnea (r=0.29 95%CI[0.13, 0.44]), between the respiratory drive and the affective component of dyspnea (r=0.29 95%CI[0.02, 0.54]) and between the sweep gas flow and the alae nasi and parasternal (r=-0.31 95%CI[-0.44, -0.22] and r=-0.25 95%CI[-0.44, -0.16]). In critically ill patients with VA-ECMO, an increase in sweep gas flow through the oxygenation membrane decreases dyspnea, possibly mediated by a decrease in respiratory drive.

The IMPACT Score: A New Score to Predict the Risk of Early Mortality in Cardiogenic Shock Patients Treated With Venoarterial Extracorporeal Membrane Oxygenation

Venoarterial extracorporeal membrane oxygenation (VA-ECMO) requires considerable human and financial resources. Few studies have focused on early mortality (ie, occurring within 72 hours after VA-ECMO implantation). The objective of this study was to establish a prognosis score-the IMPACT score (prediction of early mortality associated with VA-ECMO using preimplantation characteristics)-by determining the risk factors associated with early mortality. This was a retrospective and observational study. The study was conducted at a University hospital. This single-center retrospective study included 147 patients treated with VA-ECMO for cardiogenic shock between 2014 and 2021. The primary outcome was early mortality (ie, occurring within 72 hours after VA-ECMO implantation). Multivariate logistic regression was performed using a bootstrapping methodology to identify factors independently associated with early mortality. To construct the score, identified variables had points (pts) assigned corresponding to their odds ratio. A total of 147 patients were included in the study. Early mortality (<72 hours) was 26% (38 patients). Four variables were established: cardiac arrest (2 pts), lactate levels (3 pts), platelet count <100 g/L (4 pts), and renal-replacement therapy (5 pts). The IMPACT score had an area under the receiver operating characteristic curve of 0.78 (95% CI 0.86-0.70) to predict early mortality. In the authors' experience, 26% of patients treated with VA-ECMO presented early mortality. The IMPACT score is a reliable predictor of early mortality and may assist with VA-ECMO initiation decision-making.

Abstract 11322: Comparative Outcomes of Impella and Intra-Aortic Balloon Pump for Left Ventricular Unloading Among Patients With Cardiogenic Shock on Veno-Arterial Extracorporeal Membrane Oxygenation

Background: Cardiogenic shock (CS) is associated with high morbidity and mortality. Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is increasingly used for patients with CS. Although Impella or Intra-aortic balloon pump (IABP) is frequently used for left ventricular (LV) unloading for increased afterload during VA-ECMO therapy, there are scarce comparative outcomes data for these devices. Aims: To compare short-term outcomes of Impella and IABP in patients on VA-ECMO for CS. Methods: Using the Nationwide Readmissions Database between 2016 and 2020, we analyzed outcomes of CS patients requiring VA-ECMO based on multivariable regression and propensity score methods. Results: Of 15,980 patients on VA-ECMO, IABP and Impella were used in 19.4% and 16.4% patients, respectively. The proportion of patients managed with Impella for LV unloading significantly increased from 2016 to 2020 (6.5% vs. 25.8%; P-trend&lt;0.001). In-hospital mortality was higher in Impella group (54.8%) compared with ECMO only (50.4%) and IABP (48.4%) groups. After adjustment, LV unloading using IABP vs ECMO only was associated with lower in-hospital mortality (OR, 0.83; 95% CI, 0.70-0.98). LV unloading using Impella vs ECMO only had similar in-hospital mortality (OR, 1.09; 95% CI, 0.91-1.31) but was associated with more bleeding (OR, 1.21; 95% CI, 1.04-1.41) and more acute kidney injury (AKI) requiring hemodialysis (HD) (OR, 1.42; 95% CI, 1.13-1.77). LV unloading with Impella vs IABP was associated with greater risk of AKI requiring HD (OR, 1.49; 95% CI, 1.13-1.97), higher in-hospital mortality (OR, 1.32; 95% CI, 1.10-1.60), and high 40-day mortality (HR, 1.25; 95% CI, 1.17-1.32). Conclusions: LV unloading using Impella, compared with IABP, was not associated with improved survival at 40 days in patients treated with VA-ECMO for CS, but was associated with increased adverse events. These findings suggest a need for further studies to guide clinical practice of LV unloading in CS.

Abstract 13293: Predicting Successful ECMO Decannulation - A Novel Machine Learning Approach

Introduction: Extra Corporeal Membrane Oxygenation (ECMO) has emerged as a crucial life support intervention, yet the decision-making process for safe decannulation remains challenging due to a paucity of data. Methods: 199 patients who underwent venoarterial ECMO for cardiogenic shock between 2015 and 2021 were identified. Demographic, hemodynamic, laboratory, and echocardiographic data obtained within 24 hours of decannulation were collected. Successful decannulation was defined as survival without relapse to mechanical circulatory support or heart transplant within 30 days. The dataset was randomly split into 80/20 train-validation splits, and four machine learning models were employed. 5-fold cross-validation and error analysis were performed. Feature importance was derived from the best performing model. Results: 103 patients were successfully weaned off ECMO. Table 1 provides patient characteristics, which were used as features in the models. Among the models tested, Random Forest (RF) exhibited the highest performance (accuracy 85.0%, precision 90.0%, recall 85.7%, AUROC 0.94). Figure 1 depicts the performance for each model as well as the ranked feature importance and Receiver Operating Curve for the RF model. The most important features were mixed venous oxygen saturation, systolic blood pressure, ECMO flow rate and pulmonary diastolic blood pressure. Conclusion: This study demonstrates the successful application of machine learning in predicting ECMO weaning outcomes. Future research will add features and patients to enhance model performance with the goal of developing a clinical tool to assist physicians caring for ECMO patients.

Decannulation of Percutaneous Femoro-femoral VA-ECMO Using the Manta Vascular Closure Device

Percutaneous cannulation improved femoro-femoral veno-arterial Extracorporeal Membrane Oxygenation (VA-ECMO) results, reducing infectious complications, but remains limited by vascular complications related to the arterial decannulation. Several techniques were described to perform a percutaneous decannulation but were limited by poor results or lacking reproducibility and fit to the VA-ECMO in cardiogenic shock. We report herein a novel simplified technic for femoro-femoral VA-ECMO decannulation: the combined use of Manta® and FemoSeal® for percutaneous VA-ECMO decannulation is an easy to learn, reproducible and effective technique, and appears to improve the outcomes of VA-ECMO.

Sixteen-Year National Trends in Use and Outcomes of VA-ECMO in Cardiogenic Shock

There is a lack of data on contemporary trends in the use and outcomes of Veno-Arterial Extracorporeal Membrane Oxygenation (VA-ECMO) for cardiogenic shock (CS) at a national level. Patients with CS admitted during January 1st, 2002-December 31, 2018, were identified from the United States National Inpatient Sample. Among all patients admitted with CS, those who received VA-ECMO were identified. We report the trends in use and outcomes in terms of mortality, exit strategies and complications among all patients who received VA ECMO for CS. Among a total of approximately 1.6 million patients admitted with CS during the period from January 1st, 2002 to December 31, 2018; 25, 621(1.5 %) received VA-ECMO. There has been a 23-fold increase in the use of VA-ECMO over the study period, from 0.1 % in 2002 to 3 % in 2018, with a simultaneous decreasing trend of in hospital mortality from 77 % in 2002 to 50 % in 2018. Only approximately 15 % of VA-ECMO patients are discharged home with most survivors discharged to a skilled nursing facility or short-term rehabilitation. Moreover, only a minor proportion of patients on VA ECMO are bridged to heart replacement therapy with durable LVAD (6 %) or cardiac transplantation (2.5 %). In conclusion, the use of VA-ECMO in CS has increased 23-fold from January 2002 to December 2018 with a concomitant decrease in mortality from 77 % in 2002 to 50 % in 2018, only a minority of patients on VA-ECMO for CS are bridged to durable LVAD or cardiac transplantation.

Effect of Moderate Hypothermia vs Normothermia on 30-Day Mortality in Patients With Cardiogenic Shock Receiving Venoarterial Extracorporeal Membrane Oxygenation

The optimal approach to the use of venoarterial extracorporeal membrane oxygenation (ECMO) during cardiogenic shock is uncertain. To determine whether early use of moderate hypothermia (33-34 °C) compared with strict normothermia (36-37 °C) improves mortality in patients with cardiogenic shock receiving venoarterial ECMO. Randomized clinical trial of patients (who were eligible if they had been endotracheally intubated and were receiving venoarterial ECMO for cardiogenic shock for <6 hours) conducted in the intensive care units at 20 French cardiac shock care centers between October 2016 and July 2019. Of 786 eligible patients, 374 were randomized. Final follow-up occurred in November 2019. Early moderate hypothermia (33-34 °C; n = 168) for 24 hours or strict normothermia (36-37 °C; n = 166). The primary outcome was mortality at 30 days. There were 31 secondary outcomes including mortality at days 7, 60, and 180; a composite outcome of death, heart transplant, escalation to left ventricular assist device implantation, or stroke at days 30, 60, and 180; and days without requiring a ventilator or kidney replacement therapy at days 30, 60, and 180. Adverse events included rates of severe bleeding, sepsis, and number of units of packed red blood cells transfused during venoarterial ECMO. Among the 374 patients who were randomized, 334 completed the trial (mean age, 58 [SD, 12] years; 24% women) and were included in the primary analysis. At 30 days, 71 patients (42%) in the moderate hypothermia group had died vs 84 patients (51%) in the normothermia group (adjusted odds ratio, 0.71 [95% CI, 0.45 to 1.13], P = .15; risk difference, -8.3% [95% CI, -16.3% to -0.3%]). For the composite outcome of death, heart transplant, escalation to left ventricular assist device implantation, or stroke at day 30, the adjusted odds ratio was 0.61 (95% CI, 0.39 to 0.96; P = .03) for the moderate hypothermia group compared with the normothermia group and the risk difference was -11.5% (95% CI, -23.2% to 0.2%). Of the 31 secondary outcomes, 30 were inconclusive. The incidence of moderate or severe bleeding was 41% in the moderate hypothermia group vs 42% in the normothermia group. The incidence of infections was 52% in both groups. The incidence of bacteremia was 20% in the moderate hypothermia group vs 30% in the normothermia group. In this randomized clinical trial involving patients with refractory cardiogenic shock treated with venoarterial ECMO, early application of moderate hypothermia for 24 hours did not significantly increase survival compared with normothermia. However, because the 95% CI was wide and included a potentially important effect size, these findings should be considered inconclusive. ClinicalTrials.gov Identifier: NCT02754193.

Quality of Life Following Urgent LVAD Implantation for ECMO Therapy in Cardiogenic Shock: A Long-Term Follow-Up.

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.

Clinical efficacy of direct or indirect left ventricular unloading during venoarterial extracorporeal membrane oxygenation for primary cardiogenic shock

ObjectiveLeft ventricular (LV) distention is a feared complication in patients receiving venoarterial (VA) extracorporeal membrane oxygenation (ECMO). LV unloading can be achieved indirectly with intra-aortic balloon pump (IABP) or directly with an Impella device (Abiomed, Danvers, Mass). We sought to assess the clinical and hemodynamic effects of IABP and Impella devices on patients supported with VA ECMO. MethodsWe conducted a retrospective review of VA ECMO patients at our institution from January 2015 to June 2020. Patients were categorized as either ECMO alone or ECMO with LV unloading. LV unloading was characterized as either ECMO with IABP or ECMO with Impella. We recorded baseline characteristics, survival, complications, and hemodynamic changes associated with device initiation. ResultsDuring the study, 143 patients received ECMO alone whereas 140 received ECMO with LV unloading (68 ECMO with IABP, 72 ECMO with Impella). ECMO with Impella patients had a higher incidence of bleeding events compared with ECMO alone or ECMO with IABP (52.8% vs 37.1% vs 17.7%; P < .0001). Compared with ECMO alone, ECMO with IABP patients had better survival at 180 days (log rank P = .005) whereas survival in ECMO with Impella patients was not different (log rank P = .66). In a multivariable Cox hazard analysis, age (hazard ratio [HR], 1.02; 95% confidence interval [CI], 1.00-1.03; P = .015), male sex (HR, 0.54; 95% CI, 0.38-0.80; P = .002), baseline lactate (HR, 1.06; 95% CI, 1.02-1.11; P = .004), baseline creatinine (HR, 1.06; 95% CI, 1.00-1.11; P = .032), need for extracorporeal membrane oxygenation-cardiopulmonary resuscitation (HR, 2.09; 95% CI, 1.40-3.39; P = .001), and presence of pre-ECMO IABP (HR, 0.45; 95% CI, 0.25-0.83; P = .010) were associated with reduced mortality. There was no significant difference in hemodynamic changes in the ECMO with IABP versus ECMO with Impella cohorts. ConclusionsConcomitant support with IABP might help reduce morbidity and improve 180-day survival in patients receiving VA ECMO for cardiogenic shock.

Left Ventricular Decompression by Transaortic Catheter Venting in Extracorporeal Membrane Oxygenation.

Venoarterial extracorporeal membrane oxygenation (VA-ECMO) has been widely applied to patients with cardiogenic shock. Left ventricle (LV) decompression is important when LV distension develops with pulmonary edema. The purpose of this study was to present the results of transaortic catheter venting (TACV) performed during VA-ECMO. We retrospectively reviewed the medical records of 18 patients who underwent both VA-ECMO and TACV between January 2017 and December 2019. Venoarterial extracorporeal membrane oxygenation was applied uneventfully. Lactate level and norepinephrine requirement for patients of weaning success were lower than those of patients of weaning failure after the application of TACV (p = 0.032 and p = 0.015, respectively). The successful weaning rate of ECMO was 77.8% (15/18) and survival rate was 50% (9/18). Transaortic catheter venting may be an easy, safe, and effective technique for LV decompression in patients with VA-ECMO for cardiogenic shock. Also, this technique may be helpful as an alternative or bridge method.

Clinical and Hemodynamic Efficacy of Left Ventricular Unloading during Venoarterial Extracorporeal Membrane Oxygenation

<h3>Purpose</h3> Left ventricular (LV) distention is a feared complication in patients on venoarterial extracorporeal membrane oxygenation (VA-ECMO) for cardiogenic shock. LV unloading could be achieved with concomitant intra-aortic balloon pump (IABP) or Impella. We sought to assess the clinical and hemodynamic effects of IABP and Impella on patients supported with VA-ECMO <h3>Methods</h3> We conducted a retrospective review of patients who received VA-ECMO at our institution between January 2015 and June 2020. Patients with post-cardiotomy shock were excluded. Patients were categorized as having received either ECMO alone or ECMO+LV unloading. LV unloading was further characterized as either ECMO+IABP, or ECMO+Impella. We recorded baseline characteristics, post-operative complications, and hemodynamic changes associated with device initiation. <h3>Results</h3> During the study period, 142 patients received ECMO alone, 76 received ECMO+IABP, and 76 received ECMO+Impella. The ECMO+LV unloading group had more male patients compared to ECMO alone (70.4% vs 57.5%, p=0.026). 39.4% of ECMO alone patients survived to discharge, compared to 44.4% of ECMO+LV unloading patients (p=0.12). The ECMO+LV unloading group showed a greater decrease in mean pulmonary diastolic pressures compared to ECMO alone after 24 hours of support (-6.0 ± 8.4 mmHg vs -0.1 ± 10.8 mmHg, p = 0.032). ECMO+Impella patients had a higher incidence of bleeding events compared to ECMO alone or ECMO+IABP (52.6% vs 37.3% vs 20.8%, p = 0.0003). Kaplan Meier analysis revealed that ECMO+IABP had better survival compared to ECMO alone and ECMO+Impella (Figure 1). In a multivariable Cox-hazard analysis, age (HR= 1.02), male sex (HR=0.57), baseline lactate (HR =1.05), baseline creatinine (HR=1.06), need for ECPR (HR=2.21) and presence of IABP (HR=0.48) were independent predictors for mortality. <h3>Conclusion</h3> Concomitant support with IABP may help to reduce morbidity in patients on VA-ECMO for cardiogenic shock.

Limited Balloon Atrial Septostomy for Left Ventricular Unloading in Peripheral Extracorporeal Membrane Oxygenation

BackgroundThis study describes the authors’ experience with a limited balloon atrial septostomy technique, using a median balloon size of 15 mm, as a left ventricular (LV) unloading strategy in venoarterial extracorporeal membrane oxygenation (VA-ECMO). There has been increasing use of VA-ECMO in cardiogenic shock. Although LV unloading strategies have been suggested to improve outcomes, it is unclear which strategy is optimal. Methods and ResultsWe performed a retrospective study of patients who underwent a limited balloon atrial septostomy for LV unloading in peripheral VA-ECMO at a single center. The goal of this study was to define the procedural outcomes and clinical characteristics of these patients. Of the 12 patients identified, none had complications related to the procedure. There was a significant decrease in the mean left atrial pressure and the majority of patients had radiologic improvement in pulmonary vascular congestion. Of the 12 patients, 58.3% survived to discharge. ConclusionsLimited BAS is an elegant and safe method for unloading the LV in peripheral VA-ECMO.

Sex Related Differences in Patients with Cardiogenic Shock Requiring Extracorporeal Membrane Oxygenation

The use of extracorporeal membrane oxygenation (ECMO) for patients in cardiogenic shock has significantly increased over the past decade. However, there is a paucity of data examining gender-associated differences in the current mechanical circulatory support era. We assessed the impact of gender on outcomes in patients on venoarterial ECMO for cardiogenic shock. We retrospectively analyzed 574 adult patients who were placed on venoarterial ECMO for cardiogenic shock at our institution between Jan 2007- Dec 2018. Baseline risk factors and outcomes were assessed to compare male and female patients. Propensity score matching (PSM) was used to compare outcomes. The primary endpoint was in-hospital mortality. Secondary outcomes included limb ischemia (LI) defined as recommendation for distal perfusion cannula (DPC) or other interventions, LI interventions, DPC, stroke, bleeding, and continuous venovenous hemofiltration (CVVH) initiation. There were 394 male patients (69%) and 180 female patients (31%). In an unadjusted comparison, male patients were more likely to have coronary artery disease and hyperlipidemia and less likely to have COPD. Etiologies of shock were similar between the two groups. Male patients were also less likely to be be cannulated centrally for ECMO, though this difference was not seen after PSM. PSM compared 176 male patients to 176 female patients. There was no difference seen between men and women in in-hospital mortality (46.0% vs 42.6%, p=.59), LI (41.5% vs. 45.5%, p=0.52), LI surgery (15.3% vs. 12.5%, p=0.54), bleeding (44.3% vs. 48.9%, p=0.46), CVVH initiated (37.5% vs. 33.0%, p=0.44), and stroke (9.1% vs. 9.7%, p=1.00). Our data suggests that men who receive ECMO for cardiogenic shock are more likely to have pre-existing coronary artery disease and hyperlipidemia while women are more likely to have COPD. After correcting for such differences, there is no significant difference in outcome between male and female patients.

A Single-Center Experience with Balloon Atrial Septostomy as an Unloading Strategy in Patients on ECMO

Peripheral veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is used in refractory cardiogenic shock. However, the retrograde arterial perfusion can result in left ventricular (LV) distention and overloading, which leads to pulmonary edema and failure of LV recovery. Various LV unloading strategies have been utilized, including creation of an LV vent, use of temporary percutaneous left ventricular assist devices, and balloon atrial septostomy (BAS). Of these, BAS is a less common strategy. We sought to assess outcomes of LV unloading with BAS at our center. Thirty-seven patients undergoing VA-ECMO for cardiogenic shock between July 2018 and September 2019 were included in the study. Of these, 7 patients underwent BAS. Three of them had concurrent intra-aortic balloon pump (IABP). These patients all had the IABP inserted prior to VA-ECMO initiation and BAS. Thirty patients underwent either no unloading or unloading with LV venting, the Impella device, or IABP. The causes of cardiogenic shock and pre- and post-BAS left atrial pressures were evaluated, along with outcomes. The causes of cardiogenic shock are listed in the corresponding figure. Of the seven patients who were unloaded with the BAS strategy, three patients recovered, two died, one received an LVAD, and one underwent heart transplant. The patient who underwent LVAD implantation passed away due to post-operative RV failure. One patient in this study was converted from peripheral VA-ECMO to central VA-ECMO. Of the 7 patients, 4 of them had pre- and post-BAS left atrial pressure measured. There was a mean decrease of 5.75 mmHg. Of the patients who underwent other unloading strategies or no venting, thirteen recovered, thirteen died, and four underwent transplant or LVAD implantation. This small, single-center experience suggests that BAS could be a viable strategy of LV unloading. Further investigation needs to be undertaken to better understand patient selection.

Extracorporeal membrane oxygenation in peripartum cardiomyopathy: A review of the ELSO Registry

AimsData on the use of extracorporeal membrane oxygenation (ECMO) for cardiogenic shock in peripartum cardiomyopathy (PPCM) is limited. We queried the Extracorporeal Life Support Organization (ELSO) Registry for PPCM patients treated with ECMO in order to characterize demographic and clinical features, complications, survival, and variables associated with mortality. Methods and resultsThis was a retrospective review of patients voluntarily entered into the ELSO Registry. De-identified data was collected on patients with a diagnosis of PPCM based on ICD-9/ICD-10 coding who received ECMO between 2007 and 2019. Collected data included demographics, ECMO mode, cannulation strategies, pre-ECMO ventilator, biochemical, and hemodynamic parameters, run duration, complications, and survival to wean off ECMO and hospital discharge. Our primary outcome measure was survival to discharge. In the final analysis, 88 veno-arterial (VA) ECMO patients were included. Overall, 72% of patients were weaned off ECMO, including 10% who were weaned to ventricular assist device or heart transplantation, and 64% survived to hospital discharge. Extracorporeal cardiopulmonary resuscitation (ECPR) was performed in 11% of patients with 60% survival. Factors associated with decreased survival included neurologic complications (p = 0.03), specifically central nervous system hemorrhage (p = 0.01). ConclusionOur review is the largest to date of PPCM patients supported with VA ECMO for cardiogenic shock. ECMO and ECPR are valuable forms of short-term mechanical circulatory support with acceptable mortality profiles for PPCM patients who remain refractory to aggressive medical management. Complications should be meticulously avoided, especially neurologic complications.

Fatal pulmonary hemorrhage due to severe mitral regurgitation during venoarterial extracorporeal membrane oxygenation

Pulmonary hemorrhage (PH) during venoarterial extracorporeal membrane oxygenation (VA-ECMO) has been primarily reported in pediatric patients. We report a case of fatal PH during VA-ECMO for cardiogenic shock after myocardial infarction (MI). PH, in this case, was secondary to a triad of aortic insufficiency, left ventricle distension, and severe laminar mitral regurgitation. This case scenario, previously unreported in adults, illustrates the need for the echocardiographic assessment of left-sided heart valves prior to VA-ECMO initiation after MI as well as management considerations for massive PH in this context.

Extracorporeal Membrane Oxygenation Bridges Inoperable Patients to Definitive Cardiac Operation

Extracorporeal membrane oxygenation (ECMO) offers an opportunity for patient recovery through complete cardiopulmonary support but is associated with complications that limit duration and overall utility. We examine the role of ECMO as a potential bridge to high-risk cardiac surgery in otherwise inoperable cases. This study reports a retrospective, multi-institution experience examining all patients for whom ECMO was used preoperatively as a bridge to definitive cardiac surgery without exception. A consecutive patient database (December 2011 through August 2017) was utilized. European System for Cardiac Risk Evaluation (EuroSCORE) 2 was calculated as a metric of patient acuity and risk assessment. Observed and expected mortality were compared. Twelve adult patients fit inclusion criteria and were supported with ECMO during the study period. There were five males and seven females. Average age was 56 (39-77) years. All 12 patients were supported with venoarterial ECMO for cardiogenic shock. This was done in preparation for corrective conventional cardiac surgery. Definitive cardiac surgical procedures included complex valve (n = 5), left ventricular assist device (n = 3), coronary artery bypass grafting (CABG; n = 2), CABG/ventricular septal defect repair (n = 1), and mitral valve replacement/CABG (n = 1). Average time of ECMO support was 200 (range 113-379) hours. Three patients were decannulated from ECMO at the conclusion of definitive cardiac surgery. Risk assessed by Logistic EuroSCORE 2 ranged from 64% to 89%. Average EuroSCORE 2-predicted mortality representing all 12 patients was 77%. Thirty day mortality was 25% (3/12), and hospital mortality was 33% (4/12). Seven patients are still alive today, with a mean survival of 37 (range 2-64) months. Two deaths were associated with gastrointestinal bleeding and two with evolving liver failure. Mean difference between the EuroSCORE 2 prediction model and actual observed 30 day mortality rate was 42.33 (95% CI 36.86-47.98) with a two-tailed, one-sample t test value of p < 0.001. ECMO can successfully be utilized as a bridge to conventional cardiac surgical procedures in critically ill patients, with a historically high mortality.