The Physiologic Basis and Clinical Outcomes of Combined Impella and Veno-Arterial Extracorporeal Membrane Oxygenation Su
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REVIEW
The Physiologic Basis and Clinical Outcomes of Combined Impella and Veno-Arterial Extracorporeal Membrane Oxygenation Support in Cardiogenic Shock Hoong Sern Lim
Received: April 15, 2020 Ó The Author(s) 2020
ABSTRACT Key Summary Points Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) provides effective hemodynamic support in cardiogenic shock, but in some cases may be complicated by left ventricular (LV) distension and pulmonary edema. The Impella, a catheter-mounted microaxial pump has been used to unload the LV. Recent studies have compared the clinical outcomes of VAECMO to the combination of Impella and VAECMO. The purpose of this review is threefold: firstly, to discuss the physiological effects of Impella support in addition to VA-ECMO, secondly to review published studies on the outcome of this combined support, and thirdly to provide a practical overview of the approach to combining Impella and VA-ECMO.
Keywords: Cardiogenic shock; Extracorporeal membrane oxygenation; Physiology Digital Features To view digital features for this article go to https://doi.org/10.6084/m9.figshare.12213347. Electronic supplementary material The online version of this article (https://doi.org/10.1007/s40119020-00175-6) contains supplementary material, which is available to authorized users. H. S. Lim (&) University Hospital Birmingham, Edgbaston, Birmingham, UK e-mail: [email protected]
Left ventricular distension is a recognized complication of VA-ECMO support. Impella is an effective venting or decompression strategy during VA-ECMO support. The hemodynamic effects of Impella differ from other left ventricular venting strategies.
INTRODUCTION Peripheral VA-ECMO or extracorporeal life support (ECLS) provides effective hemodynamic support in cardiogenic shock. However, VAECMO modifies the normal hemodynamics in the lung and left ventricle, with consequent increase in left ventricular (LV) end-diastolic pressure, LV distension, and pulmonary edema in some patients. A number of LV ‘venting’ or ‘decompression’ strategies have been used with varying degrees of success to mitigate this increase in LV end-diastolic pressure (Table 1). The insertion of a left-sided Impella (2.5, CP or 5.0) is one such strategy.
Cardiol Ther
Table 1 Left ventricular venting strategies Intra-aortic balloon pump Left ventricular assist device (e.g.,: Impella 2.5, CP or 5.0) (Surgical) Left ventricular drainage Retrograde trans-aortic catheter drainage (Trans-septal) left atrial drainage Pulmonary artery catheter drainage Pulmonary venous drainage The Impella class of devices consists of catheter-mounted microaxial pumps that function as an Archimedes-screw pump, aspirating blood from the left ventricle and expelling into the aorta. The concomitant use of Impella with VAECMO was first described by Vlasselaers and colleagues in 2006 in a 13-year old boy [1]. Since that case report, this Impella-VA-ECMO combination has been increasingly deployed in the management of cardiogenic shock [2, 3]. The comparative physiology and outcome
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