Veno-Arterial Extracorporeal Membrane Oxygenation for Cardiogenic Shock

Summary

The following article highlights various steps involved in initiating and maintaining veno-arterial extracorporeal membrane oxygenation in patients with cardiogenic shock.

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 ....

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 m....

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 ext.......

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 an.......

Materials

List of materials used in this article

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