ECMELLA: a call for repetitive echocardiography and passionate monitoring of hemodynamic effects
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LETTER TO THE EDITOR
ECMELLA: a call for repetitive echocardiography and passionate monitoring of hemodynamic effects Jannik Richter1 · David Schibilsky2,3 · L. Christian Napp1 Received: 6 November 2019 / Accepted: 24 November 2019 © Japanese Society of Echocardiography 2019
Keywords Myocardial infarction · Cardiogenic shock · Hemodynamic monitoring · Pulmonary artery catheterization · Mechanical circulatory support · MCS · Impella · ECMO · ECMELLA Venoarterial ECMO (VA-ECMO) is increasingly used as mechanical circulatory support (MCS) in patients with severe cardiogenic shock [1, 2], with a strong rise since publication of the IABP-shock II trial results [3]. Although clinical and registry experience suggest efficacy of VAECMO for restoring end organ perfusion in cardiogenic shock, there are no large randomized trials confirming a benefit on outcomes. Furthermore, special effects such as afterload increase, north–south syndrome and the watershed phenomenon have to be considered [4, 5]. Given that healing and functional recovery of the acutely diseased left ventricle (LV) as well as pulmonary decongestion are impeded by afterload increase, many high-volume centers use Impella pumps for unloading/venting the LV during VA-ECMO support (“ECMELLA” or “ECPELLA” or “IMPECMO”) [6]. Retrospective studies suggest superior outcomes with this concept compared to ECMO alone [7–9]. Notwithstanding, there is considerable debate about indications and timing, as well as management during dual support and weaning. In this context, the report of Au and colleagues [10] prototypically illustrates the acute effect of LV unloading during
This comment refers to the article available online at https://doi. org/10.1007/s12574-019-00447-8. * L. Christian Napp napp.christian@mh‑hannover.de 1
Department of Cardiology and Angiology, Cardiac Arrest Center, Hannover Medical School, Carl‑Neuberg‑Str. 1, 30625 Hannover, Germany
2
Department of Cardiovascular Surgery, Heart Center University Freiburg, Bad Krozingen, Bad Krozingen, Germany
3
Faculty of Medicine, University of Freiburg, Freiburg, Germany
VA-ECMO support, which we believe deserves further comment. The authors state that the patient developed cardiogenic shock after a complex PCI. Was this patient a candidate for protected PCI? As both devices were available, what was the reason to initially use VA-ECMO instead of Impella support? Had the patient been resuscitated? Although there are no large randomized studies testing VA-ECMO against Impella support for cardiogenic shock, many considerations vote for Impella support first if shock development is detected early, e.g. during PCI. Was there a distinct reason for adding an Impella to VA-ECMO in this patient such as LV distension, smoke in the LV, a non-ejecting heart or pulmonary edema? Or was the Impella placed preemptively? We agree with the authors that the ECMO should usually be weaned first in ECMELLA patients, followed by Impellaonly support. What was the timing of therapies and the outcome in the presented pa
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