Highlights
- •Different left ventricular (LV) venting strategies allow varying degrees of LV unloading during venoarterial extracorporeal life support.
- •LV venting should be individualized to the patient and the venoarterial extracorporeal life support weaning strategy.
- •Success of LV unloading can be assessed invasively (pulmonary artery catheter) and noninvasively (echocardiography).
Abstract
Venoarterial extracorporeal life support (VA-ECLS) is a powerful tool that can provide
complete cardiopulmonary support for patients with refractory cardiogenic shock. However,
VA-ECLS increases left ventricular (LV) afterload, resulting in greater myocardial
oxygen demand, which can impair myocardial recovery and worsen pulmonary edema. These
complications can be ameliorated by various LV venting strategies to unload the LV.
Evidence suggests that LV venting improves outcomes in VA-ECLS, but there is a paucity
of randomized trials to help guide optimal strategy and the timing of venting. In
this review, we discuss the available evidence regarding LV venting in VA-ECLS, explain
important hemodynamic principles involved, and propose a practical approach to LV
venting in VA-ECLS.
Key Words
To read this article in full you will need to make a payment
Purchase one-time access:
Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online accessOne-time access price info
- For academic or personal research use, select 'Academic and Personal'
- For corporate R&D use, select 'Corporate R&D Professionals'
Subscribe:
Subscribe to Journal of Cardiac FailureAlready a print subscriber? Claim online access
Already an online subscriber? Sign in
Register: Create an account
Institutional Access: Sign in to ScienceDirect
References
Extracorporeal Life Support Organization. ECLS registry report. Available at https://www.elso.org/Portals/0/Files/Reports/2021_April/International%20Report%20April_page1.pdf. Accessed July 7, 2021.
- Venoarterial ECMO for adults: JACC scientific expert panel.J Am Coll Cardiol. 2019; 73: 698-716
- Mechanical circulatory support for cardiogenic shock in the critically ill.Chest. 2019; 156: 1008-1021
- Hemodynamics of mechanical circulatory support.J Am Coll Cardiol. 2015; 66: 2663-2674
- Venoarterial extracorporeal membrane oxygenation in cardiogenic shock.JACC Heart Fail. 2018; 6: 503-516
- Prevention and treatment of pulmonary congestion in patients undergoing venoarterial extracorporeal membrane oxygenation for cardiogenic shock.Eur Heart J. 2020; 41: 3753-3761
- Incidence and implications of left ventricular distention during venoarterial extracorporeal membrane oxygenation support.ASAIO J. 2017; 63: 257-265
- Mechanical unloading in heart failure.J Am Coll Cardiol. 2018; 72: 569-580
- Venoarterial extracorporeal membrane oxygenation for cardiogenic shock and cardiac arrest.Circ Heart Fail. 2018; 11e004905
- ECMO as a bridge to left ventricular assist device or heart transplantation.JACC Heart Fail. 2021; 9: 281-289
- Veno-arterial extracorporeal membrane oxygenation for cardiogenic shock: an introduction for the busy clinician.Circulation. 2019; 140: 2019-2037
- Outcomes of extracorporeal membrane oxygenation support for complex high-risk elective percutaneous coronary interventions: a single-center experience and review of the literature.J Invasive Cardiol. 2018; 30: 456-460
- Advanced reperfusion strategies for patients with out-of-hospital cardiac arrest and refractory ventricular fibrillation (ARREST): a phase 2, single centre, open-label, randomised controlled trial.Lancet. 2020; 396: 1807-1816
- The evolving role of the cardiac catheterization laboratory in the management of patients with out-of-hospital cardiac arrest: a scientific statement from the American Heart Association.Circulation. 2019; 139: e530e52
- SCAI clinical expert consensus statement on the classification of cardiogenic shock.Catheter Cardiovasc Interv. 2019; 94: 29-37
- Venoarterial extracorporeal membrane oxygenation in cardiogenic shock: Lifeline of modern day CICU.J Intensive Care Med. 2021; 36: 290-303
- Extracorporeal membrane oxygenation as a bridge to durable left ventricular assist device implantation in INTERMACS-1 patients.J Artif Organs. 2021 May 13; ([Epub ahead of print])https://doi.org/10.1007/s10047-021-01275-3
- Left ventricular unloading before reperfusion promotes functional recovery after acute myocardial infarction.J Am Coll Cardiol. 2018; 72: 501-514
- Unloading of the left ventricle during venoarterial extracorporeal membrane oxygenation therapy in cardiogenic shock.JACC Heart Fail. 2018; 6: 1035-1043
- Optimal strategy and timing of left ventricular venting during veno-arterial extracorporeal life support for adults in cardiogenic shock: A systematic review and meta-analysis.Circ Heart Fail. 2019; 12e006486
- Atrial septostomy for left atrial decompression during extracorporeal membrane oxygenation by Inoue balloon catheter.Circ J. 2017; 81: 1419-1423
- Left ventricular unloading during extracorporeal membrane oxygenation in patients with cardiogenic shock.J Am Coll Cardiol. 2019; 73: 654-662
- Left ventricular support in VA-ECMO: national trends and outcomes (2007-2014).J Am Coll Cardiol. 2019; 73: 820
- Left ventricular unloading is associated with lower mortality in patients with cardiogenic shock treated with venoarterial extracorporeal membrane oxygenation: results from an international, multicenter cohort study.Circulation. 2020; 142: 2095-2106
- Concomitant implantation of Impella® on top of veno-arterial extracorporeal membrane oxygenation may improve survival of patients with cardiogenic shock.Eur J Heart Fail. 2017; 19: 404-412
- Management of extracorporeal membrane oxygenation for postcardiotomy cardiogenic shock.Anesthesiology. 2021; 135: 497-507
- Modalities and effects of left ventricle unloading on extracorporeal life support: a review of the current literature.Eur J Heart Fail. 2017; 19: 84-91
- Finding the right time and place to vent.JACC Heart Fail. 2018; 6: 1044-1046
- The starling relationship and veno-arterial ECMO: Ventricular distension explained.ASAIO J. 2018; 64: 497-501
- Are two crutches better than one? The ongoing dilemma on the effects and need for left ventricular unloading during veno-arterial extracorporeal membrane oxygenation.Eur J Heart Fail. 2017; 19: 413-415
- Routine unloading in patients treated with extracorporeal membrane oxygenation for cardiogenic shock: mixed outcomes set the stage for future trials.Circulation. 2020; 142: 2107-2109
- Unloading is not the only question in cardiogenic shock.J Am Coll Cardiol. 2019; 73: 663-666
- Left ventricular unloading during veno-arterial ECMO: a simulation study.ASAIO J. 2019; 65: 11-20
- Evaluation study of congestive heart failure and pulmonary artery catheterization effectiveness: the ESCAPE trial.JAMA. 2005; 294: 1625-1633
- Complete hemodynamic profiling with pulmonary artery catheters in cardiogenic shock is associated with lower in-hospital mortality.JACC Heart Fail. 2020; 8: 903-913
- Trends in utilization and outcomes of pulmonary artery catheterization in heart failure with and without cardiogenic shock.J Card Fail. 2019; 25: 364-371
- Value of hemodynamic monitoring in patients with cardiogenic shock undergoing mechanical circulatory support.Circulation. 2020; 141: 1184-1197
- Effect of Impella during veno-arterial extracorporeal membrane oxygenation on pulmonary artery flow as assessed by end-tidal carbon dioxide.ASAIO J. 2018; 64: 502-507
- Serial plasma BNP levels in assessing inadequate left ventricular decompression on ECMO.Pediatr Cardiol. 2008; 29: 808-811
- Comparison of circulatory unloading techniques for venoarterial extracorporeal membrane oxygenation.ASAIO J. 2021; 67: 623-631
- Percutaneous left atrial unloading to prevent pulmonary oedema and to facilitate ventricular recovery under extracorporeal membrane oxygenation therapy.Interact Cardiovasc Thorac Surg. 2018; 26: 4-7
- Left ventricular unloading by Impella device versus surgical vent during extracorporeal life support.Ann Thorac Surg. 2017; 104: 861-867
- Contemporary management of cardiogenic shock: a scientific statement from the American Heart Association.Circulation. 2017; 136: e232-ee68
- Intra-aortic balloon pump effects on macrocirculation and microcirculation in cardiogenic shock patients supported by venoarterial extracorporeal membrane oxygenation.Crit Care Med. 2014; 42: 2075-2082
- Coronary versus carotid blood flow and coronary perfusion pressure in a pig model of prolonged cardiac arrest treated by different modes of venoarterial ECMO and intraaortic balloon counterpulsation.Crit Care. 2012; 16: R50
- Percutaneous short-term active mechanical support devices in cardiogenic shock: a systematic review and collaborative meta-analysis of randomized trials.Eur Heart J. 2017; 38: 3523-3531
- The effect of intraaortic balloon pumping under venoarterial extracorporeal membrane oxygenation on mortality of cardiogenic patients: an analysis using a nationwide inpatient database.Crit Care Med. 2016; 44: 1974-1979
- Effects of additional intra-aortic balloon counter-pulsation therapy to cardiogenic shock patients supported by extra-corporeal membranous oxygenation.Sci Rep. 2016; 6: 23838
- The evolving landscape of Impella use in the United States among patients undergoing percutaneous coronary intervention with mechanical circulatory support.Circulation. 2020; 141: 273-284
- Trends in the use of percutaneous ventricular assist devices: analysis of National Inpatient Sample data, 2007 through 2012.JAMA Intern Med. 2015; 175: 941-950
- Association of use of an intravascular microaxial left ventricular assist device vs intra-aortic balloon pump with in-hospital mortality and major bleeding among patients with acute myocardial infarction complicated by cardiogenic shock.JAMA. 2020; 323: 734-745
- Percutaneous mechanical circulatory support versus intra-aortic balloon pump in cardiogenic shock after acute myocardial infarction.J Am Coll Cardiol. 2017; 69: 278-287
- Impella support for acute myocardial infarction complicated by cardiogenic shock.Circulation. 2019; 139: 1249-1258
- A randomized clinical trial to evaluate the safety and efficacy of a percutaneous left ventricular assist device versus intra-aortic balloon pumping for treatment of cardiogenic shock caused by myocardial infarction.J Am Coll Cardiol. 2008; 52: 1584-1588
- Increased plasma-free hemoglobin levels identify hemolysis in patients with cardiogenic shock and a trans valvular micro-axial flow pump.Artif Organs. 2019; 43: 125-131
- Incidence and prognosis of vascular complications after percutaneous placement of left ventricular assist device.J Vasc Surg. 2015; 62: 417-423
- Vascular complications associated with percutaneous left ventricular assist device placement: a 10-year US perspective.Catheter Cardiovasc Interv. 2020; 95: 309-316
- Impella to unload the left ventricle during peripheral extracorporeal membrane oxygenation.ASAIO J. 2013; 59: 533-536
- Simultaneous venoarterial extracorporeal membrane oxygenation and percutaneous left ventricular decompression therapy with Impella is associated with improved outcomes in refractory cardiogenic shock.ASAIO J. 2019; 65: 21-28
- Venoarterial extracorporeal membrane oxygenation with concomitant Impella versus venoarterial extracorporeal membrane oxygenation for cardiogenic shock.ASAIO J. 2020; 66: 497-503
- Protecting the vulnerable left ventricle: the art of unloading with VA-ECMO.Circ Heart Fail. 2019; 12e006581
- Limited balloon atrial septostomy for left ventricular unloading in peripheral extracorporeal membrane oxygenation.J Card Fail. 2021; 27: 501-504
- Percutaneous balloon atrial septostomy on top of venoarterial extracorporeal membrane oxygenation results in safe and effective left heart decompression.Eur Heart J Acute Cardiovasc Care. 2018; 7: 70-79
- 2020 EACTS/ELSO/STS/AATS expert consensus on post-cardiotomy extracorporeal life support in adult patients.J Thorac Cardiovasc Surg. 2021; 161: 1287-1331
- Evaluation of a heparin monitoring protocol for extracorporeal membrane oxygenation and review of the literature.J Thorac Dis. 2019; 11: 3325-3335
- Extracorporeal cardiopulmonary resuscitation in adults. Interim guideline consensus statement from the Extracorporeal Life Support Organization.ASAIO J. 2021; 67: 221-228
- Weaning of extracorporeal membrane oxygenation using continuous hemodynamic transesophageal echocardiography.J Thorac Cardiovasc Surg. 2013; 146: 1474-1479
- Pulse pressure as a prognostic marker in patients receiving extracorporeal life support.Resuscitation. 2013; 84: 1404-1408
- A pragmatic approach to weaning temporary mechanical circulatory support: a state-of-the-art review.JACC Heart Fail. 2021; 9: 664-673
- Direct bridging to cardiac transplantation with the surgically implanted Impella 5.0 device.Clin Transplant. 2020; 34: e13818
- The multiple options of left atrial and ventricular venting during veno-arterial extra-corporeal membrane oxygenation: practical considerations.Eur Heart J. 2021; 42: 2399-2400
- Demographics, care patterns, and outcomes of patients admitted to cardiac intensive care units: the Critical Care Cardiology Trials Network Prospective North American Multicenter Registry of Cardiac Critical Illness.JAMA Cardiol. 2019; 4: 928-935
- A collaborative cardiologist-intensivist management model improves cardiac intensive care unit outcomes.J Am Coll Cardiol. 2017; 70: 1422-1423
- A standardized and comprehensive approach to the management of cardiogenic shock.JACC Heart Fail. 2020; 8: 879-891
Article info
Publication history
Published online: December 19, 2021
Accepted:
December 6,
2021
Received in revised form:
November 24,
2021
Received:
September 15,
2021
Identification
Copyright
© 2021 Elsevier Inc. All rights reserved.
