Venoarterial Extracorporeal Membrane Oxygenation as a Bridge to Recovery or Bridge to Heart Replacement Therapy in Refra
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CARDIOGENIC SHOCK: PROGRESS IN MECHANICAL CIRCULATORY SUPPORT (JE RAME, SECTION EDITOR)
Venoarterial Extracorporeal Membrane Oxygenation as a Bridge to Recovery or Bridge to Heart Replacement Therapy in Refractory Cardiogenic Shock F. Sertic 1 & C. Bermudez 1 & J. E. Rame 2 Accepted: 15 October 2020 # Springer Science+Business Media, LLC, part of Springer Nature 2020
Abstract Purpose of the Review The purpose of this review is to describe the outcomes following refractory cardiogenic shock (CS) requiring mechanical circulatory support and factors associated with successful and unsuccessful weaning from VA-ECMO. Based on the presented data, we will propose a weaning and bridging algorithm with the aim of facilitating this complex process. Recent Findings Refractory CS requiring VA-ECMO support is associated with high early mortality. Approximately 1/3 of the patients weaned from ECMO do not survive until hospital discharge. When evaluating the ability to wean from ECMO etiology of CS, hemodynamics, end-organ function, pulmonary blood oxygenation, metabolic status, and echocardiographic assessments must be considered. When cardiopulmonary function is not recoverable, heart replacement therapies (HRT) should be considered early as patients may have better outcomes. Summary Durable weaning from VA-ECMO is obtainable in well-selected patients. Patients should be separated from the ECMO circuit in the presence of myocardial recovery, hemodynamic stability, and restored end-organ function. If myocardial recovery is unsatisfactory (severe LV dysfunction), HRT should be considered early in suitable candidates. Future research is needed to identify predictors of sustained myocardial recovery. Keywords Extracorporeal membrane oxygenation . Recovery . Heart replacement therapy . Ventricular assist device . Weaning . Orthotopic heart transplant
Introduction The use of venoarterial extracorporeal membrane oxygenation (VA-ECMO) and other short-term circulatory assist devices to support patients in refractory cardiogenic shock (CS) has rapidly increased in the US over the last decade [1, 2]. VAECMO can be used as the first line of support in patients with This article is part of the Topical Collection on Cardiogenic Shock: Progress in Mechanical Circulatory Support * F. Sertic [email protected] 1
Department of Surgery, Hospital of the University of Pennsylvania, University of Pennsylvania, Philadelphia, PA, USA
2
Department of Medicine, Sydney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, USA
refractory cardiopulmonary failure due to various etiologies [3–11] as a bridge to recovery [12–19, 20•] or bridge to advanced heart replacement therapies (HRT), including left ventricular assist devices [21–24] (LVADs) and orthotopic heart transplantation (OHT) [25–27]. VA-ECMO support allows hemodynamic and metabolic stabilization with restoration of end-organ perfusion, and, after a few days of support, the patient can be weaned and separated from the ECMO circuit if there are signs cons
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