Veno-arterial-ECMO in the intensive care unit: From technical aspects to clinical practice

Abstract

The use of veno-arterial extracorporeal membrane oxygenation (VA-ECMO) as a salvage therapy in cardiogenic shock is becoming of current practice. While VA-ECMO is potentially a life-saving technique, results are sometimes mitigated, emphasising the need for selecting the right indication in the right patient. This relies upon a clear definition of the individual therapeutic project, including the potential for recovery as well as the possible complications associated with VA-ECMO. To maximise the benefits of VA-ECMO, the basics of extracorporeal circulation should be perfectly understood since VA-ECMO can sometimes be detrimental. Hence, to be successful, VA-ECMO should be used by teams with sufficient experience and initiated after a thorough multidisciplinary discussion considering patient's medical history, pathology as well the anticipated evolution of the disease.

Weaning from veno-arterial extra-corporeal membrane oxygenation: which strategy to use?

“…Veno-arterial extracorporeal membrane oxygenation (VA ECMO) may be used to rescue patients with refractory cardiogenic shock (1)(2)(3)(4)(5)(6)(7)(8)(9)(10). The main indication for VA ECMO may be medical cardiogenic shock, including that associated with acute myocardial infarction, fulminant myocarditis, acute exacerbation of severe chronic heart failure, drug intoxication, hypothermia and acute circulatory failure due to intractable arrhythmia (1)(2)(3)(4)(5)(6)(7). VA ECMO may also be used for patients with post-cardiotomy cardiac failure or after cardiac or pulmonary transplantation, or cardiac arrest requiring cardiopulmonary resuscitation (1,4,8).…”

“…The main indication for VA ECMO may be medical cardiogenic shock, including that associated with acute myocardial infarction, fulminant myocarditis, acute exacerbation of severe chronic heart failure, drug intoxication, hypothermia and acute circulatory failure due to intractable arrhythmia (1)(2)(3)(4)(5)(6)(7). VA ECMO may also be used for patients with post-cardiotomy cardiac failure or after cardiac or pulmonary transplantation, or cardiac arrest requiring cardiopulmonary resuscitation (1,4,8). VA ECMO may be used in some particular situations for patients with pulmonary embolism, sepsis associated cardiomyopathy and pulmonary hypertension (1)(2)(3)(4)(5)(6)(7)(8)(9)(10).…”

“…VA ECMO may also be used for patients with post-cardiotomy cardiac failure or after cardiac or pulmonary transplantation, or cardiac arrest requiring cardiopulmonary resuscitation (1,4,8). VA ECMO may be used in some particular situations for patients with pulmonary embolism, sepsis associated cardiomyopathy and pulmonary hypertension (1)(2)(3)(4)(5)(6)(7)(8)(9)(10).…”

Hematologic concerns in extracorporeal membrane oxygenation

“…Other risks associated with VA ECMO vary among patient populations, indications, and cannulation technique. Complications include hemorrhage in 30%‐70% of patients, stroke in 4%‐12% , limb ischemia in 12%‐22%, and left ventricular distention, which both delays separation from ECMO and increases areas of stasis and hematologic complications 1‐7 . Assessing the true risk of complications associated with ECMO is difficult because of the differences in populations, indications (including cardiac arrest, low cardiac output, and respiratory failure), cannulation techniques, circuitry, and anticoagulation strategies.…”

Impella to unload the left ventricle in patients undergoing venoarterial extracorporeal membrane oxygenation for cardiogenic shock: A systematic review and meta‐analysis

“…It is associated with immediate improvement in blood pressure and hemodynamics. However, it also results in an increased afterload in an already failing left ventricle (LV) 7‐9 . Many strategies directed at unloading the LV have been attempted, including pulmonary vein or transseptal left atrial cannulation, intra‐aortic balloon pump (IABP), percutaneous mechanical circulatory support, or transapical cannulation.…”