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JoVE Journal Medicine

Medicine

Veno-Arterial Extracorporeal Membrane Oxygenation for Cardiogenic Shock

Published: September 1, 2023 doi: 10.3791/62052
1, 2, 3, 2
1Cardiovascular Medicine, Mayo Clinic, 2Cardiovascular Medicine, University of Nebraska Medical Center, 3Cardiothoracic Surgery, University of Nebraska Medical Center

Abstract

Cardiogenic shock (CS) is a clinical condition characterized by inadequate tissue perfusion in the setting of low cardiac output. CS is the leading cause of death following acute myocardial infarction (AMI). Several temporary mechanical support devices are available for hemodynamic support in CS until clinical recovery ensues or until more definitive surgical procedures have been performed. Veno-arterial (VA) extracorporeal membrane oxygenation (ECMO) has evolved as a powerful treatment option for short-term circulatory support in refractory CS. In the absence of randomized clinical trials, the utilization of ECMO has been guided by clinical experience and based on data from registries and observational studies. Survival to hospital discharge with the use of VA-ECMO ranges from 28-67%. The initiation of ECMO requires venous and arterial cannulation, which can be performed either percutaneously or by surgical cutdown. Components of an ECMO circuit include an inflow cannula that draws blood from the venous system, a pump, an oxygenator, and an outflow cannula that returns blood to the arterial system. Management considerations post ECMO initiation include systemic anticoagulation to prevent thrombosis, left ventricle unloading strategies to augment myocardial recovery, prevention of limb ischemia with a distal perfusion catheter in cases of femoral arterial cannulation, and prevention of other complications such as hemolysis, air embolism, and Harlequin syndrome. ECMO is contraindicated in patients with uncontrolled bleeding, unrepaired aortic dissection, severe aortic insufficiency, and in futile cases such as severe neurological injury or metastatic malignancies. A multi-disciplinary shock team approach is recommended while considering patients for ECMO. Ongoing studies will evaluate whether the addition of routine ECMO improves survival in AMI patients with CS who undergo revascularization.

Introduction

Cardiogenic shock (CS) is a clinical condition characterized by inadequate tissue perfusion in the setting of low cardiac output. Despite advances in reperfusion therapy, acute myocardial infarction (AMI) remains the leading cause of CS. According to an analysis of the National Inpatient Sample (NIS) database, which collects data from approximately 20% of all United States hospitalizations, 55.4% of 144,254 CS cases between 2005 and 2014 were secondary to AMI1. Other etiologies of CS include decompensated heart failure, fulminant myocarditis, post cardiotomy shock, and pulmonary embolism (PE). CS is associated with a high in-hospital mortality rate, ranging between 45-65%1,2. Thus, rapid identification of CS and correction of reversible causes is critical in improving patient survival. For instance, the Should We Emergently Revascularize Occluded Coronaries for Cardiogenic Shock (SHOCK) trial demonstrated that a strategy of early revascularization was associated with better survival at 6 months3 and 1 year4 compared to a strategy of initial medical stabilization in patients with CS complicating AMI.

Vasopressors and inotropes can be used to correct hypotension associated with CS, but neither have been shown to have any mortality benefit5,6,7. Short-term mechanical circulatory support (MCS) devices, on the other hand, can provide hemodynamic support in patients with refractory CS as a bridge to recovery or as a bridge to more definitive therapy. The use of MCS has seen an increase in the recent decade; however, the incidence of CS hospitalizations has outpaced the utilization of MCS8. A declining trend in the utilization of intra-aortic balloon pumps (IABP) has been countered by a relative increase in the application of intravascular micro-axial left ventricular assist devices (LVAD) (e.g., Impella and TandemHeart) and veno-arterial extracorporeal membrane oxygenation (VA-ECMO).

VA-ECMO can generate flows up to 4-6 L/min and its application in CS has gained significant popularity9. According to a global registry maintained by the Extracorporeal Life Support Organization (ELSO), the use of VA-ECMO increased from less than 500 runs per year prior to 2010 to 2,157 runs in 201510. Nonetheless, VA-ECMO is a resource-intensive modality and requires round-the-clock availability of specialized equipment and trained staff. Therefore, patient selection is critically important prior to the initiation and maintenance of ECMO in order to improve outcomes and minimize adverse events. This article discusses the steps involved in initiation of VA-ECMO, post initiation maintenance, evidence behind its use,  and associated complications.

An ECMO circuit consists of an inflow cannula, centrifugal pump, oxygenator, and outflow cannula (Figure 1)11. The inflow cannula is connected via tubing to a centrifugal pump, in which a spinning rotor generates flow and pressure. From the pump, blood flows to a membrane oxygenator where gas exchange takes place12. Here, the hemoglobin is saturated with oxygen, and the degree of oxygenation is controlled by changing the flow rate and increasing or decreasing the fraction of inspired oxygen (FiO2) supplied to the oxygenator. The removal of carbon dioxide is controlled by adjusting the sweep speed of the countercurrent gas passing through the oxygenator. A heat exchanger is usually attached to the oxygenator, and the temperature of blood returning to the body can thus be adjusted. From the oxygenator, blood is returned to the patient through an outflow cannula, either peripherally in the femoral artery or centrally in the aorta.

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Protocol

This protocol follows the guidelines of the institutional human research ethics committee at the University of Nebraska Medical Center.

1. Patient selection

  1. Consider VA-ECMO in patients with refractory CS as a bridge to recovery when the myocardial function is anticipated to improve following the initial insult, as a bridge to decision-making, or as a bridge to a more definitive therapy such as durable LVAD or cardiac transplantation when myocardial dysfunction is irreversible.
    NOTE: Various indications include CS secondary to AMI, end-stage heart failure, fulminant myocarditis, and cor pulmonale due to massive PE13,14,15,16,17. Another area of growing use is in patients undergoing cardiac surgery who develop refractory post cardiotomy CS18.
  2. Utilize VA-ECMO in selected patients with out-of-hospital cardiac arrest secondary to refractory ventricular fibrillation/ventricular tachycardia for cardiopulmonary support as a part of extracorporeal cardiopulmonary resuscitation (ECPR).
    NOTE: Limited evidence suggests that ECPR is associated with improved survival and is now incorporated in guidelines for CPR19,20.
  3. Refrain from using VA-ECMO in scenarios involving severe irreversible end-organ failure that limits survival, such as advanced malignancy, brain injury, aortic dissection, and when the patient's goals of care do not align with the use of MCS21.
    ​NOTE: Some relative contraindications include peripheral vascular disease hindering cannulation, uncontrolled bleeding, or a contraindication to the use of anticoagulants. Old age (>70 years) is not an absolute contraindication; however, this population historically has shown poor in-hospital survival compared to younger adults22.

2. Cannulation and initiation of VA-ECMO

  1. Facilitate an interdisciplinary team-based discussion comprising advanced heart failure specialists, interventional cardiologists, cardio-thoracic surgeons, and critical care intensivists prior to initiating CS patients on VA-ECMO23.
  2. Perform the cannulation in the cardiac catheterization laboratory, the emergency department, or the intensive care unit for a percutaneous approach (peripheral cannulation), or in the operating room for a surgical approach (central cannulation)24.
  3. For the percutaneous approach, clean and prepare the access sites using an antiseptic solution such as chlorhexidine.
  4. Under ultrasound guidance, obtain femoral venous access using a modified Seldinger technique with a needle and place a 5 Fr micro sheath25.
  5. Advance a flexible J tip guidewire (0.038 in x 180 cm) through the femoral vein into the inferior vena cava (IVC) and direct it to the right atrium.
  6. Dilate the venous access site using sequential dilators to serially dilate the cannula passage, stepping up by one dilator (2 Fr sizes). Then place an appropriately sized venous cannula (single lumen).
    NOTE: The size of the cannula is determined based on the age, sex, and diameter of the vessel on the ultrasound, as well as the desired flows. The venous cannula is available in 21 Fr to 25 Fr sizes, and a 25 Fr cannula will usually suffice for most adults.
  7. Confirm the tip of the venous cannula is at the junction of the intrahepatic portion of the IVC and the right atrium with fluoroscopy or plain X-ray.
  8. Obtain arterial access, usually in the contralateral femoral artery, in a similar fashion using the modified Seldinger technique and then place a micro sheath (5 Fr).
  9. Advance a flexible J-tip guidewire (0.038 in X 180 cm) or a stiff guidewire into the common femoral artery and then into the aorta.
  10. Place an arterial cannula of appropriate size (15-21 Fr) after the progressive dilation of skin and subcutaneous tissue with dilators.
    NOTE: The cannula size is selected to provide a cardiac index of >2.4 L/min/m2. A 19 Fr arterial cannula will provide sufficient support for most adults; however, for smaller females, a smaller size cannula should be used.
  11. Place a distal perfusion catheter (DPC) for antegrade perfusion in the ipsilateral superficial femoral artery by the modified Seldinger technique usinga micro-puncture needle. Introduce a 5 Fr DPC and attach it to the side port of the arterial cannula using 6-7" extension tubing26.
    NOTE: Progressively larger size arterial cannulae increase the risk of ischemic complications in the ipsilateral limb, especially in patients with underlying peripheral vascular disease.
  12. Secure both venous and arterial cannulae in place by suturing them to the skin with nonabsorbable 2.0 silk sutures.
    NOTE: Central cannulation is routinely done in the operating room and typically requires sternotomy.
  13. Perform direct cannulation of the right atrium and aorta after thoracotomy. Secure these in place using purse-string 4.0 prolene sutures, snuggers, and spigots.
  14. Then, fix the cannulae to the chest wall from within the cavity using multiple sutures.
  15. Leave the chest open with an occlusive dressing or closed at the conclusion. Tunnel the cannulae through the skin when the chest is closed.
  16. Connect the cannulae (arterial and venous) to the ECMO circuit and increase the blood flow until respiratory and hemodynamic parameters are achieved.

3. Post initiation management

  1. Patient monitoring
    1. Place a 7.5 Fr pulmonary artery catheter to aid clinical decision-making with periodic measurements of the pulmonary artery pressure and pulmonary capillary wedge pressure as a surrogate for left ventricular filling pressures.
      NOTE: This helps in identifying patients who are at risk of developing pulmonary edema, since VA-ECMO creates a right-to-left shunt by draining venous blood from the right atrium and returning oxygenated blood to the iliac arteries/descending aorta. While preload is reduced, an increase in afterload with VA-ECMO can increase the risk of pulmonary edema in patients with CS who already have an underlying LV dysfunction.
    2. Place the arterial lines in the right radial or left radial arteries using the micropuncture technique with the help of guidewire27.
      NOTE: This helps determine the location of the watershed (area in the aortic arch where the antegrade flow from the left ventricle meets the retrograde flow from the arterial cannula)28.
    3. Monitor the oxygen saturations from the right radial artery site to assess upper body (cerebral and right upper extremity) oxygenation. Perform arterial blood gas analysis every 8-12 h to ensure adequate oxygenation29.
    4. Adjust FiO2 on the oxygenator (dial up the knob) to maintain 60-100 mmHg PaO2.
      NOTE: FiO2 is usually set at 100% at the initiation of VA-ECMO and is subsequently titrated down as oxygenation improves.
    5. Optimize the ventilation and, thus, carbon dioxide removal by adjusting the sweep speed to between 3-7 L/min to correct for any respiratory acidosis.
    6. Serially monitor markers of end-organ perfusion such as lactate, SvO2, transaminases, and creatinine clearance by venous gas analysis30,31.
      NOTE: Goal SvO2 should be >70% and lactate less than 2.2 mmol/L.
  2. Adjusting the flow and management of venous chatter
    1. Adjust the flow through the circuit to allow for adequate end-organ perfusion (target flow of 60 cc/kg/min). Change the flow by adjusting the speed of the pump. Maintain a flow of 4-6 L/min initially after cannulation.
      NOTE: Higher speeds of the pump, hypovolemia, and malpositioned venous cannula can lead to venous chatter, which manifests as suctioning or "chugging" of the venous cannula32. Venous chatter can lead to hemolysis by causing a vacuum in the pump head, as the rotor in the pump continues to spin and evacuate blood from the pump.
    2. Correct the venous chatter by fluid resuscitation in cases of hypovolemia. Reposition the venous cannula in case of malpositioning or kinking. Reduce the speed of the pump in case of high speed33,34.
    3. Minimize the venous chatter by attaching a venous reservoir or a collapsible bladder to the inflow cannula. This allows to reduce suctioning of the inflow cannula by providing volume to the pump.
  3. Left ventricular unloading
    NOTE: An increase in afterload from the retrograde VA-ECMO flow can lead to a higher LV end-diastolic pressure (LVEDP) and thus worsen pulmonary edema, and and severe cases of LV standstill may lead to thrombus formation from stagnated blood35.
    1. To unload the LV and decrease afterload, utilize inotropes such as dobutamine (starting dose of 1-2 µg/kg/min) or vasodilators such as hydralazine or nitrates36,37,38.
      NOTE: However, these are usually insufficient, and mechanical unloading of LV may be required.
    2. Place a ventricular support device (e.g., Impella) or intra-aortic balloon pump (IABP) percutaneously to accomplish direct unloading of the LV. To accomplish indirect unloading of the LV, place a pulmonary artery cannula percutaneously or perform balloon septostomy.
      NOTE: Surgical techniques, including transseptal left atrial drainage or direct cannulation of the LV apex, can also be employed for LV unloading39.
  4. Anticoagulation
    1. Initiate systemic anticoagulation at the time of cannulation. Use a bolus of 50-100 IU/kg of IV heparin (recommended) followed by continuous heparin as below.
    2. Continue unfractionated heparin to maintain an activated partial thromboplastin time or activated clotting time of at least 1.5 times the upper limit of normal during lab checks (every 4-6 h).
    3. In patients with heparin-induced thrombocytopenia, use direct thrombin inhibitors such as bivalirudin (starting dose of 0.025-0.05 mg/kg/h)40 or argatroban (starting dose of 0.05-2 µg/kg/min)41 to reach therapeutic levels.

4. Prevention and management of complications

  1. Harlequin (North-South) syndrome
    NOTE: Differential cyanosis of the upper body can occur when the watershed (the area where retrograde flow containing oxygenated blood from the outflow cannula meets antegrade blood the from LV) is distal to the origin of aortic arch branch vessels in the setting of concomitant respiratory failure. Deoxygenated blood from the LV supplies the upper body through the carotid and subclavian arteries, while the lower body is supplied by the blood from the outflow cannula of VA-ECMO. This phenomenon is called Harlequin syndrome or North-South syndrome (the upper body is blue, and the lower body is pink).
    1. Manage this differential cyanosis by increasing the oxygen saturation of blood returning to the LV by either increasing the FiO2 or positive end-expiratory pressure if the patient is on mechanical ventilation or by returning oxygenated blood to the right atrium, typically through another cannula introduced in the internal jugular vein connected to the arterial limb of the ECMO circuit (V-A-V ECMO).
    2. Monitor the upper body oxygenation saturation every 8-12 h with arterial gas analysis (ABG) from the right radial artery. Adequate tissue oxygenation is ensured with 60-100 mmHg of PaO2 on ABG42.
  2. Lower limb ischemia
    NOTE: One of the most serious complications of peripheral arterial cannulation is antegrade ischemia in the lower extremity that rarely leads to compartment syndrome and, in extreme situations, may require amputation43. The incidence of limb ischemia is variable, ranging from 10% to 70%, as reported by different studies44.
    1. Choose an appropriate size cannula based on the diameter of the femoral arteries on the ultrasound, thus potentially decreasing lower limb ischemic complications.
    2. Monitor lower limb circulation following cannulation using serial pulse doppler or near-infrared spectroscopy (NIRS)44. NIRS is a non-invasive imaging tool to access tissue oxygentaion45.
    3. Perform continuous assessment of lower extremity tissue oxygenation using NIRS. Place the sensor pads on calf muscles connected to an oximeter to readily detect any change in tissue oxygenation, which is an indicator of perfusion.
    4. Insert an antegrade perfusion catheter (5-7 Fr) in the superficial femoral artery at the time of ECMO cannulation to prevent ischemic complications in the lower extremity.
  3. Bleeding and hemolysis
    NOTE: A small degree of hemolysis is common after VA-ECMO initiation. Causes of significant hemolysis include pump thrombosis and clotting in the ECMO circuit.
    1. Carefully monitor for clinically significant hemolysis. Measure hemoglobin levels, lactate dehydrogenase, bilirubin, and creatinine daily.
    2. Consider interrupting systemic anticoagulation in patients with severe bleeding and thrombocytopenia46. However, this may increase the risk of thrombotic complications; thus, careful assessment of bleeding and thrombotic risks should be done prior to holding anticoagulation.
  4. Air embolism
    NOTE: Air entrapment in the ECMO circuit can occur from loose connections, peripheral or central venous access, or rupture of the oxygenator membrane47. It can lead to air embolism, which can cause a stroke if air bubbles enter cerebral circulation.
    1. Lay the patient in the Trendelenburg position while on ventilatory support and clamp the ECMO circuit to manage air embolism
    2. De-air and re-prime the circuit when air embolism is suspected. Occasionally, the entire circuit may need replacement.

5. Weaning from ECMO

  1. Assess the patients for weaning once they have recovered from the initial insult that prompted the use of VA-ECMO.
    NOTE: Concomitant respiratory failure must have been resolved prior to weaning.
  2. Perform serial echocardiograms to assess for improvement in cardiac function and readiness for weaning.
  3. Confirm hemodynamic stability prior to weaning a patient from VA-ECMO.
    NOTE: Patients must have recovered pulsatile arterial waveform for at least 24 h, and the mean arterial pressure should be >60 mmHg in the absence of or with low dose vasopressor use48.
  4. While weaning, perform an echocardiographic turndown study, where the ECMO flow is gradually decreased to a minimum of 1-1.5 L/min. Ensure hemodynamic stability and assess cardiac function on an echocardiogram.
    NOTE: Left ventricular (LV) ejection fraction of >20%-25%, aortic velocity-time integral of >10 cm, and lateral mitral annulus peak systolic velocity of >6 cm/s during the turndown study are predictors of successful weaning49.
  5. Monitor laboratory parameters of end-organ perfusion such as lactate, SvO2, and renal function while patients are being weaned.
  6. To facilitate the weaning process, place a simplified weaning bridge50 between the patient and the ECMO circuit prior to decannulation (this step is optional).
    NOTE: The weaning bridge allows patients to be observed off ECMO support and provides an opportunity to turn back on the ECMO circuit whenever required in a few minutes. It consists of a long tubing that connects inflow and outflow cannulae.
  7. Place clamps on both inflow and outflow cannulae proximal to the weaning bridge, toward the patient side, thus separating the patient from the ECMO circuit and allowing blood to recirculate within the ECMO circuit.
  8. After clamping the circuit, observe the patients for up to 24 h prior to decannulation. In case hemodynamic support is required, re-initiate ECMO flow by simply removing the tubing clamps.
  9. To further augment weaning, use a ventricular support device (e.g., Impella) which can provide up to 5 L/min of flow. Increase the flow from the ventricular support device and turn down VA-ECMO flow systematically while ensuring hemodynamic stability.
    NOTE: One of the benefits of the ventricular support device is that it can be implanted using an axillary approach, thus allowing for early ambulation after the removal of VA-ECMO51.
  10. Once the patient is deemed a candidate for removal of VA-ECMO, perform decannulation in the operating room or cardiac catheterization laboratory.
    NOTE: Most patients with peripheral arterial cannulation will require some degree of vascular repair.

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Representative Results

Survival to hospital discharge after the use of VA-ECMO in refractory CS ranges from 28- 67%13,15,52,53,54,55,56, as reported by various observational studies (Table 1). The outcomes vary based on the etiology of CS. In the ELSO registry, 9,025 adults were supported with extracorporeal life support (ECLS) from 1990 to 2015. CS was the most common diagnosis associated with ECLS use, with a survival to discharge rate of only 42%10. Adults with myocarditis had the best survival (65%), whereas adults with a congenital heart defect had the worst survival (37%). Post cardiotomy CS represents another population with worse in-hospital outcomes after the initiation of VA-ECMO with in-hospital survival ranging between 30-40%53,54. A meta-analysis of 17 studies showed that LV unloading in VA-ECMO was associated with a decrease in mortality when compared to no unloading57.Various complications from VA-ECMO itself can lead to an increase in morbidity and mortality associated with CS. For instance, bleeding events were noted in 45-60% of patients on ECMO58,59and a higher activated partial thromboplastin time has been associated with an increased risk of hemorrhagic complications. A recent meta-analysis of 44 studies60 evaluating long-term survival after the use of VA-ECMO in refractory CS showed that aggregated survival at 1 and 5 years was 36.7% and 29.9% respectively. Thus, despite the use of VA-ECMO as a rescue modality in patients with CS, both in-hospital and long-term mortality remain high. Furthermore, some evidence suggests that successful weaning of VA-ECMO does not always predict survival48. In-hospital mortality in patients successfully weaned off from VA-ECMO is about 25%61. A recent multicenter randomized controlled ECMO-CS trial of 117 patients demonstrated that early use of VA-ECMO for stage D-E shock did not improve clinical outcomes compared with an early conservative management that permitted downstream use of VA-ECMO in case of worsening hemodynamics62. In contrast, a single center randomized control ARREST trial63 demonstrated that early ECMO-facilitated resuscitation for out-of-hospital cardiac arrest and refractory ventricular fibrillation improved survival to hospital discharge compared with standard advanced cardiovascular life support (ACLS) treatment. Future research should focus on identifying patients at risk of adverse events following weaning and decannulation of VA-ECMO.

Figure 1
Figure 1: Schematic diagram showing various components of the veno-arterial extracorporeal membrane oxygenation (VA-ECMO) circuit. The inflow cannula brings blood from the body into the ECMO pump from where the blood is sent to an oxygenator for oxygenation. The temperature of the blood is optimized before it is sent back to the body via an outflow cannula inserted in a large bore artery (most commonly in the femoral artery). Please click here to view a larger version of this figure.

Author, year Country Design Total number of patients (n) Etiology of cardiogenic shock In-hospital survival (%)
Aso, 201615 Japan Retrospective 4658 Ischemic heart disease, heart failure, valvular heart disease, myocarditis 26.4
Smith, 201752 Global Retrospective 2699 Myocarditis, coronary artery disease, structural heart disease, post heart transplantation, post ventricular assist device 41.4
Chen, 201753 Taiwan Retrospective 1141 Post-cardiotomy shock 38.3
Thiagarajan, 201710 USA Retrospective 9025 multifactorial 42
Rastan, 201054 Germany Retrospective 517 coronary artery bypass grafting, valve surgery, coronary artery bypass grafting plus valve surgery, thoracic organ transplantation, others 24.8

Table 1: Select observational studies reporting in-hospital survival in patients with cardiogenic shock (CS) who underwent veno-arterial extracorporeal membrane oxygenation (VA-ECMO). These studies highlight that in-hospital survival of patients requiring ECMO remains low ranging between 24.8-42%.

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Discussion

In this protocol, various steps involved in the initiation and maintenance of VA-ECMO in patients with refractory CS are described. Some of the major complications, weaning parameters, and outcomes with the use of VA-ECMO have also been discussed.

VA-ECMO is usually employed as a rescue therapy when other management strategies fail to provide adequate hemodynamic support in CS. Cannulation involves large bore vascular access which should be performed meticulously to minimize vascular injury and bleeding risk. Once VA-ECMO has been initiated, patients should be monitored in the cardiovascular intensive care unit equipped with perfusionists and nurses who have received specialized training in handling ECMO circuits. Patients should be assessed for weaning daily and decannulation should be performed as early as possible once cardiac recovery occurs or when more definitive therapies have been identified in an effort to minimize complications.

VA-ECMO utilization has increased tremendously over the last two decades with an expanding list of indications. Despite an increase in availability and prevalence of use, mortality in CS remains high. Patient selection is critical in ensuring the judicious allocation of resources while also mitigating complications associated with VA-ECMO. Several scoring systems have been developed to predict the survival of patients undergoing VA-ECMO. Survival after veno-arterial-ECMO (SAVE) score61 was created using data from the ELSO registry and is useful in predicting survival in patients prior to VA-ECMO initiation. Scoring is done based on the etiology of CS, age, weight, acute organ failures (renal, liver, and/or central nervous system), chronic renal failure, duration of intubation, peak inspiratory pressure, diastolic and mean pulse pressures, cardiac arrest, and bicarbonate values. Based on the SAVE score, patients are risk stratified into five different risk classes (Class I to V). Lower scores are associated with a higher risk class and worse in-hospital survival rates. This scoring system was also externally validated in 161 Australian patients and showed excellent discrimination with an area under the receiving operating characteristics curve of 0.90 (95% confidence interval of 0.85-0.95). The modified SAVE score64 incorporating lactate was subsequently developed and was shown to have excellent outcome prediction in patients undergoing VA-ECMO initiation within 24 hours of arrival in the emergency department. Another simplified prognostication tool called PREDICT VA-ECMO score65 utilizing point-of-care biomarker (lactate, pH, and bicarbonate concentration) measurements at 1, 6, and 12 hours was recently developed and validated.The identification of patient populations at risk of adverse events after VA-ECMO and subsequent utilization of more definitive therapies remains an area of ongoing interest.

Limited evidence suggests that early initiation of VA-ECMO after the diagnosis of CS may improve survival13. ECMO-CS trial by Ostadal et al. did not show difference in mortality from any cause in patients receiving early VA-ECMO therapy versus conservative strategy62. However, this has not yet been validated in a randomized fashion. Testing the Value of Novel Strategy and its Cost Efficacy in Order to Improve the Poor Outcomes in Cardiogenic Shock (EUROSHOCK) trial (ClinicalTrials.gov Identifier: NCT03813134) is an ongoing randomized clinical trial that will evaluate whether the early initiation of ECMO in AMI patients with CS improves 30-day survival when compared to standard treatment. Similarly, the Extracorporeal Life Support in Cardiogenic Shock (ECLS-SHOCK) trial (ClinicalTrials.gov Identifier: NCT03637205) will examine whether ECLS in addition to revascularization and medical therapy is beneficial when compared to no use of ECLS in AMI complicated by CS. ECLS will preferentially be initiated prior to revascularization in this trial.

The initiation and maintenance of VA-ECMO requires substantial healthcare resources which may only be available in tertiary care hospitals. Local communities in collaboration with health care systems should focus on developing a "spoke and hub model"66 with peripheral smaller hospitals referring patients with CS promptly after diagnosis to a central tertiary hospital with organized VA-ECMO teams.

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Disclosures

John Um is a consultant for Abbott Laboratories and a consultant for Medtronic. Poonam Velagapudi discloses receiving speaking fee from Abiomed, Medtronic, Opsens, and Shockwave Medical and fee for participating in advisory boards at Abiomed and Sanofi. The other authors have nothing to disclose.

Acknowledgments

None.

Materials

Name Company Catalog Number Comments
Amplatz Super Stiff guidewire Boston Scientific 46-500, 46-501, 46-502. 46-503, 46-504, 46-517, 46-519, 46-520, 46-523, 46-525, 46-526, 46-563, 46-564, 46-509, 46-510, 46-518, 46-524 Allows delivery of catheters across tortuous anatomies
Impella Abiomed Impella 2.5, Impella CP, Impella 5.0, Impella 5.5, Impella RP Percutaneously inserted left ventricular assist device that provides hemodynamic support in cardiogenic shock 
Inflow Cannula Surge Cardiovascular FEM-V1020, FEM-V1022, FEM-V1024, FEM-V1026,FEM-V1028 Removes deoxygenated blood from the central venous circulation into the ECMO circuit
Inflow Cannula Medtronic Cardiopulmonary Biomedicus 96600-019,021,023,025,027,029 Removes deoxygenated blood from the central venous circulation into the ECMO circuit
Inflow Cannula Medtronic Cardiopulmonary Biomedicus Femoral Venous 96670 - 017,019, 021, 023 Removes deoxygenated blood from the central venous circulation into the ECMO circuit
Inflow Cannula Medtronic Cardiopulmonary Biomedicus Multi-Stage Femoral Venous 96880-019,021,025 Removes deoxygenated blood from the central venous circulation into the ECMO circuit
Inflow Cannula Medtronic Cardiopulmonary Biomedicus NextGen 96600 - 115, 117, 119, 121, 123, 125, 127, 129 Removes deoxygenated blood from the central venous circulation into the ECMO circuit
Inflow Cannula Medtronic Cardiopulmonary Carmeda Biomedicus CB96605-015,017,019,021,023,025,29  Removes deoxygenated blood from the central venous circulation into the ECMO circuit
Inflow Cannula Medtronic Cardiopulmonary Cortiva Biomedicus Femoral Venous CB96670-015,017,019,021 Removes deoxygenated blood from the central venous circulation into the ECMO circuit
Inflow Cannula Medtronic Cardiopulmonary DLP Carmeda Venous CB75008, CB66112, CB66114, CB66116, CB66118, CB66120, CB66122,CB66124 Removes deoxygenated blood from the central venous circulation into the ECMO circuit
Inflow Cannula Getinge Avalon Elite Bicaval - 10013, 10016, 10019, 10020, 10023, 10027, 10031 Removes deoxygenated blood from the central venous circulation into the ECMO circuit
Inflow Cannula Getinge HLS Cannula Venous Bioline - BE PVS 1938, 2138, 2155, 2338, 2355, 2538, 2555, 2955 Removes deoxygenated blood from the central venous circulation into the ECMO circuit
Inflow Cannula Getinge HLS Cannula Venous Softline - BO PVS 1938, 2138, 2155, 2338, 2355, 2538, 2555, 2955 Removes deoxygenated blood from the central venous circulation into the ECMO circuit
Inflow Cannula Getinge HLS Cannula Venous - PVS 1938, 2138, 2155, 2338, 2355, 2538, 2555, 2955 Removes deoxygenated blood from the central venous circulation into the ECMO circuit
Inflow Cannula Medtronic Cardiopulmonary Life Support Bio-Medicus Drainage Catheter and Introducers - LS96218 - 015, 017, 019, 021, 023, 025 ; LS96438 - 021, 023, 025, LS 96555 - 019, 021, 023, 025, LS 96355 - 021, LS96360 -023, 025, 027, 029 Removes deoxygenated blood from the central venous circulation into the ECMO circuit
Inflow Cannula Fresenius Medos Femoral Cannula MEFKV 18,20,22,24,26,28 Removes deoxygenated blood from the central venous circulation into the ECMO circuit
Inflow Cannula Medtronic Cardiopulmonary Medtronic 2 stage venous - 91228, 91240, 91246, 91236,91251 Removes deoxygenated blood from the central venous circulation into the ECMO circuit
Inflow Cannula Senko/Mera PCKC-V-24, PCKC-V2-18, PCKC-V-18, PCKC-V2-20, PCKC-V-20, PCKC-V-22, PCKC-V2-24, PCKC-V-24 Removes deoxygenated blood from the central venous circulation into the ECMO circuit
Inflow Cannula TandemLife/Livanova 29,31 Fr Removes deoxygenated blood from the central venous circulation into the ECMO circuit
Inflow Cannula Freelife Medical FLK V19 B18, FLK V19 B18R, FLK VV 19R, FLK V20 B20, FLK V20 B20R, FLK V19 B20, FLK V19 B20R, FLK V20 B22, FLK V20 B22R, FLK V10S B22, FLK V19 B22, FLK V19 B22R, FLK V10 B22, FLK V10 B22R, FLK V10S B22R, FLK VV 23R, FLK V10S B24, FLK V10S B24R, FLK V10 B24, FLK V10 B24R, FLK V10S B26, FLK V10S B26R, FLK V10 B26, FLK V10 B26R, FLK VV 27R, FLK VV 31R Removes deoxygenated blood from the central venous circulation into the ECMO circuit
Inflow Cannula LivaNova Sorin right angle venous - 10, 12, 14, 16, 18, 20, 22, 24, 28 Removes deoxygenated blood from the central venous circulation into the ECMO circuit
Inflow Cannula Terumo CX-EB18VLX, CX-EB21VLX Removes deoxygenated blood from the central venous circulation into the ECMO circuit
Outflow Cannula Medtronic Cardiopulmonary Biomedicus Arterial 96530 - 015,017, 019, 021, 023, 025,   Returns oxygenated blood to the body
Outflow Cannula Medtronic Cardiopulmonary Biomedicus Femoral Arterial 96570 - 015, 017, 019, 021 Returns oxygenated blood to the body
Outflow Cannula Medtronic Cardiopulmonary Biomedicus NextGen Arterial 96530 -115, 117, 119, 121, 123, 125, 96570 - 115, 117, 119, 121 Returns oxygenated blood to the body
Outflow Cannula Medtronic Cardiopulmonary Carmeda Biomedicus CB96535 - 015, 017, 019, 021, 023 Returns oxygenated blood to the body
Outflow Cannula Medtronic Cardiopulmonary Cortiva Biomedicus Femoral Arterial CB96570 -015, 017, 019, 021 Returns oxygenated blood to the body
Outflow Cannula Getinge PAS 1315, PAS 1515, PAS 1523, PAS 1717, PAL 1723, PAL 1923, PAL 2115, PAL 2123, PAL 2315, PAL 2323 Returns oxygenated blood to the body
Outflow Cannula Getinge Bioline BE PAS 1315, BE PAS 1515, BE PAL 1523, BE PAL 1723, BE PAS 1915, BE PAL 1923, BE PAS 2115, BE PAL 2123, BE PAS 2315, BE PAL 2323,  Returns oxygenated blood to the body
Outflow Cannula Getinge Softline BO PAS 1315, BO PAS 1515, BO PAL 1523, BO PAS 1715, BO PAL 1723, BO PAS 1915, BO PAL 1923, BO PAS 2115, BO PAL 2123, BO PAL 2323 Returns oxygenated blood to the body
Outflow Cannula Fresenius Medos Femoral Arterial Cannula; MEFKA 16, 18, 20, 22,24 Returns oxygenated blood to the body
Outflow Cannula Senko/Mera PCKC-A-20, PCKC-A-16, PCKC-A-18  Returns oxygenated blood to the body
Outflow Cannula Freelife Medical FLK A18 D16, FLK A18L D16, FLK A18L D16R, FLK A18 D16R, FLK A44 D18, FLK A44 D18R, FLK A18 D18, FLK A18L D18, FLK A18L D18R, FLK A18 D18R, FLK A44 D20, FLK A44 D20R, FLK A18 D20, FLK A18L D20, FLK A18L D20R, FLK A18 D20R, FLK A18 D22, FLK A18L D22, FLK A18L D22R, FLK A18 D24, FLK A18L D24, FLK A18L D24R, FLK A18 D24R Returns oxygenated blood to the body
Outflow Cannula LivaNova Sorin arterial - 14, 17, 19, 21, 23 Fr Returns oxygenated blood to the body
Outlflow Cannula Medtronic Cardiopulmonary Life Support Bio-Medicus Return Catheter and Introducers - LS96010-009, LS96010-011, LS96010-013, LS96010-015, LS96218-015, LS96218-017, LS96218-019, LS96218-021, LS96218-023, LS96218-025 Returns oxygenated blood to the body
Oxygenator Abbott Eurosets Deoxygenated blood from the inflow cannula is saturated with oxygen
Oxygenator Getinge MaquetHLS Set Advanced v 5.0, v 7.0, Maquet Quadrox iD Deoxygenated blood from the inflow cannula is saturated with oxygen
Oxygenator Medtronic Nautilus Deoxygenated blood from the inflow cannula is saturated with oxygen
Pump Abiomed Breethe Generates force to deliver oxygenated blood back to the body
Pump LivaNova Alcard ALC 250 Generates force to deliver oxygenated blood back to the body
Pump Baxter Century Roller Pump Generates force to deliver oxygenated blood back to the body
Pump Medtronic Cardiopulmonary Biomedicus BP50, BP80 Centrifugal Generates force to deliver oxygenated blood back to the body
Pump Braile Biomedica Safyre Generates force to deliver oxygenated blood back to the body
Pump Getinge CiSet Generates force to deliver oxygenated blood back to the body
Pump Abbott CentriMag Generates force to deliver oxygenated blood back to the body
Pump LivaNova Cobe 6" Roller Generates force to deliver oxygenated blood back to the body
Pump Origen FloPump 32 Generates force to deliver oxygenated blood back to the body
Pump Getinge HIT Set Advanced Softline 5.0 and 7.0 Generates force to deliver oxygenated blood back to the body
Pump LivaNova LifeSPARC Generates force to deliver oxygenated blood back to the body
Pump Senko/Mera Centrifugal pump head Generates force to deliver oxygenated blood back to the body
Pump  Getinge HLS Set Advanced Bioline 5.0 and 7.0 Generates force to deliver oxygenated blood back to the body
Tandem Heart LivaNova Tandem Heart LS Percutaneously inserted left ventricular assist device

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References

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Tags

Veno-Arterial Extracorporeal Membrane Oxygenation Cardiogenic Shock Low Cardiac Output Temporary Mechanical Support Devices Hemodynamic Support Refractory CS Clinical Trials ECMO Circuit Inflow Cannula Pump Oxygenator Outflow Cannula Systemic Anticoagulation Left Ventricle Unloading Strategies Myocardial Recovery Limb Ischemia Distal Perfusion Catheter
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Jhand, A., Shabbir, M. A., Um, J.,… More

Jhand, A., Shabbir, M. A., Um, J., Velagapudi, P. Veno-Arterial Extracorporeal Membrane Oxygenation for Cardiogenic Shock. J. Vis. Exp. (199), e62052, doi:10.3791/62052 (2023).

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