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Medicine

Veno-Arterial Extracorporeal Membrane Oxygenation for Cardiogenic Shock

Published: September 1st, 2023

DOI:

10.3791/62052

1Cardiovascular Medicine, Mayo Clinic, 2Cardiovascular Medicine, University of Nebraska Medical Center, 3Cardiothoracic Surgery, University of Nebraska Medical Center

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

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.

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 ....

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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 .......

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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.......

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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.......

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None.

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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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