Therapeutic strategy using extracorporeal life support, including appropriate indication, management, limitation and timing of switch to ventricular assist device in patients with acute myocardial infarction

Abstract

The appropriate indication for, management of and limitations to extracorporeal life support (ECLS) and the timing of a switch to a ventricular assist device (VAD) remain controversial issues in patients with acute myocardial infarction (AMI) complicated with cardiogenic shock or cardiopulmonary arrest. To evaluate and discuss these issues, we studied patients with AMI treated with ECLS and compared deceased and discharged patients. Thirty-eight patients with AMI who needed ECLS [35 men (92.1 %), aged 59.9 ± 13.5 years] were enrolled in this study. Of these 38 patients, 34 subsequently underwent percutaneous coronary intervention (PCI), and four subsequently received coronary artery bypass grafting (CABG). Fourteen patients (36.8 %) were discharged from the hospital. The outcome was not favorable for those patients with deteriorating low output syndrome (LOS) and the development of leg ischemia, hemolysis and multiple organ failure during ECLS. Levels of creatine kinase, creatine kinase-MB (CK-MB), lactate dehydrogenase, serum creatinine (Cr) and amylase after the patient had been put on ECLS and fluctuation of the cardiac index, blood pressure, arterial blood gas analysis and CK-MB and Cr levels during ECLS were indicators to switch from the ECLS to VAD. In the case of patients with no complication associated with ECLS, 4.6-5.6 days after initiation of ECLS was assumed to be the threshold to decide whether to switch from ECLS to VAD. Patients with AMI who suddenly developed refractory pulseless ventricular tachycardia or ventricular fibrillation without deteriorating LOS and who underwent successful PCI or CABG, and who prevented the complications associated with ECLS, showed a high probability of recovering with ECLS.

Managing cardiac arrest with refractory ventricular fibrillation in the emergency department: Conventional cardiopulmonary resuscitation versus extracorporeal cardiopulmonary resuscitation

“…Our study suggests that the timely use of ECMO helped to maintain perfusion to vital organs such as the myocardium and the brain during the resuscitation process, which contributed to improved neurological outcomes. 32 This study has several limitations, notably that it was a retrospective observational study rather than a randomized controlled trial. It is not possible to randomize our patients to E-CPR or C-CPR in clinical practice.…”

Extracorporeal life support in the multidisciplinary management of cardiogenic shock complicating acute myocardial infarction

“…26 Our results are consistent with previous articles that reported survival rates after ECLS for AMI complicated by cardiogenic shock comprised between 33 and 66%. [5][6][7][8][9][10][11][12][13][14][15][16] Preliminary data identified ECLS support for primary PCI as a significant contributor to the reduction of in-hospital mortality in patients with cardiogenic shock due to AMI. 5 The ideal timing--before or after primary PCI--of ECLS implantation in STEMI patients developing cardiogenic shock is still matter of debate.…”

“…2 ECLS showed encouraging results in critical patients with AMI-related cardiogenic shock and previous articles reported survival rates after ECLS support between 33 and 66%. [5][6][7][8][9][10][11][12][13][14][15][16] We sought to analyze the results and outcomes of ECLS for cardiogenic shock complicating AMI in a single-center experience.…”

ECMO Used in a Refractory Ventricular Tachycardia and Ventricular Fibrillation Patient

“…However, ECMO use produced favorable outcomes for patients with ACS with refractory VF or pulseless VT. 13 Furthermore, a retrospective study found that acute myocardial infarction patients who required ECMO support and suddenly developed refractory pulseless VT or VF without deteriorating low output syndrome had a high probability of recovering with ECMO use. 14 Moreover, an international study (SAVE-score) predicted the survival rate before ECMO use in refractory cardiogenic shock patients and determined that refractory VT/VF were protective factors. 9 In addition, an observational study in a medical center included patients who had refractory ventricular arrhythmia because of acute myocardial infarction and found that ECMO is a feasible rescue therapy that can lead to further therapy.…”