Hybrid extracorporeal membrane oxygenation.
TL;DR: All these "hybrid" approaches, such as the addition of a third or fourth ECMO cannula to improve venous drainage and/or optimize systemic hemodynamics/oxygenation, or the implementation of surgical or percutaneous unloading of the left ventricle (LV), to reduce cardiac dilation and pulmonary edema are described.
Abstract: Veno-venous (VV) and veno-arterial (VA) extracorporeal membrane oxygenation (ECMO) therapy is widely used in critically ill patients with refractory cardiogenic shock and cardiac arrest or suffering from severe respiratory failure. Besides traditional ECMO cannulation, changes in patients' conditions or the occurrence of specific complications (i.e., cerebral hypoxia or left ventricular dilation) may require modifications in cannulation strategies or the combination of ECMO with additional invasive or minimally invasive procedures, to improve organ function and ECMO efficiency. In this review, we described all these "hybrid" approaches, such as the addition of a third or fourth ECMO cannula to improve venous drainage and/or optimize systemic hemodynamics/oxygenation, or the implementation of surgical or percutaneous unloading of the left ventricle (LV), to reduce cardiac dilation and pulmonary edema. Although few data are still available about the effectiveness of such interventions, clinicians should be aware of these advances in ECMO management to improve the management of more complex cases.
Citations
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TL;DR: The authors have attempted to create a concise, comprehensive and relevant analysis of all aspects related to PC-ECLS, with a particular emphasis on indications, technique, management, and avoidance of complications.
49 citations
Maastricht University Medical Centre1, Johns Hopkins University2, Erasmus University Medical Center3, Cardiovascular Institute of the South4, ISMETT5, University of Düsseldorf6, University of Michigan7, Hospital of the University of Pennsylvania8, Vanderbilt University Medical Center9, Harvard University10
TL;DR: A concise, comprehensive and relevant analysis of all aspects related to PC-ECLS, with a particular emphasis on indications, technique, management and avoidance of complications, appraisal of new approaches and ethics, education and training is created.
Abstract: Post-cardiotomy extracorporeal life support (PC-ECLS) in adult patients has been used only rarely but recent data have shown a remarkable increase in its use, almost certainly due to improved technology, ease of management, growing familiarity with its capability and decreased costs. Trends in worldwide in-hospital survival, however, rather than improving, have shown a decline in some experiences, likely due to increased use in more complex, critically ill patients rather than to suboptimal management. Nevertheless, PC-ECLS is proving to be a valuable resource for temporary cardiocirculatory and respiratory support in patients who would otherwise most likely die. Because a comprehensive review of PC-ECLS might be of use for the practitioner, and possibly improve patient management in this setting, the authors have attempted to create a concise, comprehensive and relevant analysis of all aspects related to PC-ECLS, with a particular emphasis on indications, technique, management and avoidance of complications, appraisal of new approaches and ethics, education and training.
37 citations
TL;DR: A concise, comprehensive and relevant analysis of all aspects related to PC-ECLS, with a particular emphasis on indications, technique, management and avoidance of complications, appraisal of new approaches and ethics, education and training is created.
31 citations
TL;DR: Key considerations discussed in this review include hemodynamic assessment and goals; pharmacologic anticoagulation; ECMO weaning strategies; and the prevention, evaluation, and treatment of common complications.
18 citations
24 Feb 2021
TL;DR: The authors of this Invited Expert Opinion address modifications to traditional circuitry when peripheral cannulation does not appear sufficient and augmentation of venous drainage or ECMO flow is necessary.
Abstract: Although hybrid and parallel ECMO circuits may prove useful in managing certain patients, generally these strategies should not be used as the initial means of cannulation. Rather, patients should be supported with isolated VA or VV ECMO with the understanding that patient conditions are dynamic and they may require a modification to their modality of support during their course. This may require optimization of the existing circuit, changing cannulation site (eg, femoral artery to axillary artery), conversion from one modality to another, the employment of hybrid or parallel ECMO circuits, or even conversion to central cannulation, and de-escalation from there as the patients’ status changes. Further, cannula position should be optimized and medical management should be maximized.
Patients who ultimately require a hybrid or parallel ECMO support represent a small fraction of total patients receiving ECMO, as illustrated by Extracorporeal Life Support Organization data. In general, survival is lower in these patients, with adult respiratory patients having a survival of 32% with V-AV support compared to 60% with VV support, and adult cardiac patients having a survival of 32% with V-AV support compared with 41% with VA support.7 There are currently no data that clearly establish a mortality benefit of the use of hybrid or parallel circuits. The high mortality associated with these strategies likely reflects the severity of illness of patients who require hybrid strategies compared with those who are supported with isolated VV or VA ECMO.
Mechanical circulatory support is a complex landscape, and patients requiring support have dynamic disease processes. With the myriad of ECMO configurations and mechanical circulatory support devices that are available, each patient requires an individualized approach. The determination must be made of the appropriate cannulation strategy for ECMO and whether to use it in isolation or in concert with another circulatory support device to best fit each patient.
Conflict of Interest Statement
David J. Kaczorowski has a patent for devices for endovascular access through extracorporeal life support circuits. All other authors reported no conflicts of interest.
The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest.
18 citations
Cites background from "Hybrid extracorporeal membrane oxyg..."
...In patients on VA ECMO, a venous return cannula can be added to the circuit either via the right internal jugular vein or the femoral veins, allowing for the return of oxygenated blood to the right circulatory system and can be helpful in the setting of harlequin syndrome.(4) Access and positioning of the cannula is no different from positioning a venous return cannula in a patient supported on isolated VV ECMO, or an arterial return cannula in a patient support on isolated VA ECMO, respectively (Figure 1)....
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...Although throttle valves can allow for precise adjustment of flow distribution, they can lead to turbulent flow and have potential for hemolysis in the long term.(4,6,10,13) Without a throttle valve, if a larger venous cannula is used compared with an arterial cannula, flows will consistently be greater in venous compared with arterial return up to 7 L/min total flow....
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...addition of a venous return cannula.(4,5) In both cases, there is one venous drainage cannula and the return is split between a venous and arterial return, resulting in veno-arteriovenous (V-AV) ECMO....
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References
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TL;DR: Veno‐arterial extracorporeal membrane oxygenation (VA‐ECMO) support stabilizes patients with cardiogenic shock and may be impeded due to the increased afterload, resulting in a failing static left ventricle and in high mortality.
Abstract: Aims
Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) support stabilizes patients with cardiogenic shock. Despite improved oxygenation and peripheral circulation, LV unloading may be impeded due to the increased afterload, resulting in a failing static left ventricle and in high mortality.
Methods and results
We describe for the first time a large series of patients treated with the combination of VA-ECMO and Impella® compared with patients with VA-ECMO only. We retrospectively collected data on patients from two tertiary critical care referral centres. We enrolled 157 patients treated with VA-ECMO from January 2013 to April 2015: 123 received VA-ECMO support and 34 had concomitant treatment with VA-ECMO and Impella. A propensity-matching analysis was performed in a 2:1 ratio, resulting in 42 patients undergoing VA-ECMO alone (control group) compared with 21 patients treated with VA-ECMO and Impella. Patients in the VA-ECMO and Impella group had a significantly lower hospital mortality (47% vs. 80%, P < 0.001) and a higher rate of successful bridging to either recovery or further therapy (68% vs. 28%, P < 0.001) compared with VA-ECMO patients. A higher need for continuous veno-venous haemofiltration (48% vs. 19%, P = 0.02) and increased haemolysis (76% vs. 33%, P = 0.004) were reported in the study group due to higher survival. There was no difference in major bleeding rates between the two groups (VA-ECMO and Impella 38% vs. VA-ECMO 29%, P = 0.6).
Conclusions
Concomitant treatment with VA-ECMO and Impella may improve outcome in patients with cardiogenic shock compared with VA-ECMO only. Nevertheless, randomized studies are needed to validate these promising results further.
395 citations
TL;DR: Extracorporeal membrane oxygenation is an acceptable technique for short-term treatment of refractory postoperative low cardiac output and can save the lives of a group of very high risk patients.
306 citations
TL;DR: Adequate decompression of the left atrium can be achieved by transseptal placement of a left atrial drain incorporated into the ECMO circuit, and this technique represents a reasonable alternative to blade or balloon atrial septostomy for patients requiringleft atrial decompression.
Abstract: Objectives:When extracorporeal membrane oxygenation (ECMO) is used in the setting of severe myocardial dysfunction, left ventricular end-diastolic and left atrial pressure can rise to extremely high levels. Decompression of the left atrium in this setting is essential for resolution of pulmonary ede
180 citations
TL;DR: The aim of this study was to provide a comprehensive overview regarding the different LV venting techniques and results currently available in the literature.
Abstract: Introduction/Aim
Veno‐arterial extracorporeal membrane oxygenation (V‐A ECMO) support is increasingly used in refractory cardiogenic shock and cardiac arrest, but is characterized by a rise in afterload of the left ventricle (LV) which may ultimately either further impair or delay cardiac contractility improvement. The aim of this study was to provide a comprehensive overview regarding the different LV venting techniques and results currently available in the literature.
Methods
A systematic literature search was performed in the PubMed database: 207 articles published between 1993 and 2016 were included. Papers dealing with pre‐clinical studies, overlapping series, and association with other assist devices were excluded from the review, with 45 published papers finally selected. Heterogeneous indications for LV unloading were reported. The selected literature was divided into subgroups, according to the location or the performed procedure for LV venting.
Results
Case reports or case series accounted for 60% of the papers, while retrospective study represented 29% of them. Adult series were present in 67%, paediatric patients in 29%, and a mixed population in 4%. LV unloading was performed percutaneously in 84% of the cases. The most common locations of unloading was the left atrium (31%), followed by indirect unloading (intra‐aortic balloon pump) (27%), trans‐aortic (27%), LV (11%), and pulmonary artery (4%). Percutaneous trans‐septal approach was reported in 22%. Finally, the unloading was conducted surgically in 16%,with open chest surgery in 71%, and minimally invasive surgery in 29% of surgical cases.
Conclusion
Nowadays, only a few data are available about left heart unloading in V‐A ECMO support. Despite the well‐known controversy, IABP remains widely used in combination with V‐A ECMO. Percutaneous approaches utilizing unloading devices is becoming an increasingly used option. However, further studies are required to establish the optimal LV unloading method.
179 citations
TL;DR: BBAS alleviates severe left atrial hypertension and pulmonary edema and avoids the potential bleeding complications of surgical left heart decompression, which may permit recovery of LV function or allow extended ECMO support as a bridge to transplant.
Abstract: Extracorporeal membrane oxygenation (ECMO) is used as circulatory support or bridge to transplantation in patients with severe left ventricular (LV) dysfunction. Left heart decompression is needed to reduce pulmonary edema, prevent pulmonary hemorrhage, and reduce ventricular distention that may aid in recovery of function. We reviewed our experience from November 1993 to December 1997 with 10 patients having severe LV dysfunction (7 myocarditis, 3 dilated cardiomyopathy) who required circulatory support with ECMO and who underwent left heart decompression with blade and balloon atrial septostomy (BBAS). Patients ranged in age from 1 to 24 years (median, 3 years). Indications for BBAS included left atrial/left ventricular distension (10), pulmonary edema/hemorrhage (9), or severe mitral regurgitation (2). BBAS was performed electively in eight patients and urgently in two patients. BBAS was performed while on ECMO in seven patients and pre-ECMO in three. A femoral venous approach was used in all patients. ECMO patients were fully heparinized. Transseptal puncture was required in nine patients while one patient had a patent foramen ovale. Blade septostomy was performed in all patients. Enlargement of the defect was then performed by stationary balloon dilation in nine and Rashkind balloon atrial septostomy in one. Balloon diameters ranged from 10 to 20 mm. Sequential balloon inflations were performed in some patients. Adequacy of the atrial septal defect (ASD) was confirmed by pressure measurement and echocardiography. Adequate left heart decompression was achieved in all patients. Pulmonary edema improved in nine of nine patients. Left atrial mean pressure fell from a mean of 30.5 mm Hg, (range, 12-50 mm Hg) to 16 mm Hg (range, 9-24 mm Hg). Left atrial to right atrial pressure gradient fell from a mean of 20 mm Hg pre-BBAS to 3 mm Hg post-BBAS. ASDs ranged in size from 2.5 to 8 mm (mean, 5.9 mm). Complications included needle perforation of the left atrium without hemodynamic compromise (one), ventricular fibrillation requiring defibrillation (one), and hypotension following BBAS which responded to volume infusion (two). Duration of ECMO ranged from 41 hr to 704 hr (mean, 294 hr). Seven patients survived and four patients had recovery of normal LV function. Of those who recovered, two had no ASD at follow-up while two ASDs are patent 14 days and 3 months post-BBAS. Three patients underwent successful cardiac transplantation. Three patients died, all of whom had multisystem organ failure with or without sepsis. A patent ASD was noted at transplant (three) or autopsy (two). No patient required a second BBAS. BBAS alleviates severe left atrial hypertension and pulmonary edema. In addition, BBAS avoids the potential bleeding complications of surgical left heart decompression. Stationary balloon dilation of the atrial septum is an effective alternative to Rashkind balloon septostomy in older patients. BBAS achieves left heart decompression that may permit recovery of LV function or allow extended ECMO support as a bridge to transplant.
172 citations