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Extracorporeal Membrane Oxygenation and Short-Term Mechanical Circulatory Support

Trevor A. Ellison, MD, PhD, Ahmet Kilic, MD, Chun W. Choi, MD, Errol L Bush, MD, FACS
Extracorporeal Membrane Oxygenation and Short-Term Mechanical Circulatory Support is a topic covered in the Adult and Pediatric Cardiac.

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Introduction

Although heart and lung transplants remain the gold standard treatment for end-stage heart and lung failure, respectively, the limited number of organ donors has challenged the evolution of mechanical circulatory and ventilatory support devices. In recent years, there has been an increased utilization of short-term mechanical circulatory and ventilatory devices to offer lifesaving therapy in patients who are in cardiopulmonary failure.

Outside of lung transplantation, ventilatory compromise or end-stage lung failure has been treated with ventilator support, such as high-frequency oscillating ventilation and patient proning; medications, such as inhaled nitric oxide, epoprostenol, and surfactant; and treatment of the underlying causative agent. Since the 1970s, venovenous extracorporeal membrane oxygenation (VV ECMO) has been used to supplement inadequate native lung function by oxygenating and removing carbon dioxide from the entire blood volume.

The pursuit to address cardiac failure has led to the development of a large host of circulatory devices in addition to ECMO. This chapter will focus on the short-term devices. Patients in refractory cardiogenic shock are often not eligible for long-term cardiac replacement solutions (eg, heart transplantation [HT], durable ventricular assist device [VAD], or total artificial heart [TAH]) in the acute setting. In these situations, a short-term mechanical circulatory support device (MCSD) option is needed in order to support the patient hemodynamically. This short-term MCSD serves as a bridge to recovery, bridge to transplantation, bridge to durable support (VAD, TAH), bridge to decision (allowing a trial of support to aid in deciding if support will lead to recovery, lead to the need for durable support, or be futile), or bridge to bridge (replacing the short-term MCSD with a longer-term MCSD in order to gain more time in a bridge-to-decision fashion). In addition to short-term support in refractory cardiogenic shock, some of these devices are now used as prophylactic support for high-risk patients undergoing interventional cardiac catheterization procedures such as high-risk percutaneous coronary intervention (PCI), percutaneous valve therapies, and electrophysiology diagnostics and therapies.

Over the past decades, a number of short-term MCSDs have been developed. The oldest and most commonly used device is the intra-aortic balloon pump (IABP). Other devices include veno-arterial (VA) ECMO, Impella, TandemHeart, CentriMag, Rotaflow, and others. Some of these devices are placed exclusively percutaneously or by vessel cutdown (the Impella and TandemHeart), and some can be placed percutaneously or surgically (IABP, VA ECMO).

This era of short-term MCSDs is still relatively young, and there is a paucity of randomized studies to definitively guide device and patient selection.[1] The following sections lay out the common indications, maintenance, weaning, complications, and outcomes of these devices based on published guidelines by the International Society for Heart and Lung Transplantation, the Society for Cardiovascular Angiography and Interventions, the American College of Cardiology Foundation, the Heart Failure Society of America, The Society of Thoracic Surgeons, and the Extracorporeal Life Support Organization as well as data from current literature.

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Introduction

Although heart and lung transplants remain the gold standard treatment for end-stage heart and lung failure, respectively, the limited number of organ donors has challenged the evolution of mechanical circulatory and ventilatory support devices. In recent years, there has been an increased utilization of short-term mechanical circulatory and ventilatory devices to offer lifesaving therapy in patients who are in cardiopulmonary failure.

Outside of lung transplantation, ventilatory compromise or end-stage lung failure has been treated with ventilator support, such as high-frequency oscillating ventilation and patient proning; medications, such as inhaled nitric oxide, epoprostenol, and surfactant; and treatment of the underlying causative agent. Since the 1970s, venovenous extracorporeal membrane oxygenation (VV ECMO) has been used to supplement inadequate native lung function by oxygenating and removing carbon dioxide from the entire blood volume.

The pursuit to address cardiac failure has led to the development of a large host of circulatory devices in addition to ECMO. This chapter will focus on the short-term devices. Patients in refractory cardiogenic shock are often not eligible for long-term cardiac replacement solutions (eg, heart transplantation [HT], durable ventricular assist device [VAD], or total artificial heart [TAH]) in the acute setting. In these situations, a short-term mechanical circulatory support device (MCSD) option is needed in order to support the patient hemodynamically. This short-term MCSD serves as a bridge to recovery, bridge to transplantation, bridge to durable support (VAD, TAH), bridge to decision (allowing a trial of support to aid in deciding if support will lead to recovery, lead to the need for durable support, or be futile), or bridge to bridge (replacing the short-term MCSD with a longer-term MCSD in order to gain more time in a bridge-to-decision fashion). In addition to short-term support in refractory cardiogenic shock, some of these devices are now used as prophylactic support for high-risk patients undergoing interventional cardiac catheterization procedures such as high-risk percutaneous coronary intervention (PCI), percutaneous valve therapies, and electrophysiology diagnostics and therapies.

Over the past decades, a number of short-term MCSDs have been developed. The oldest and most commonly used device is the intra-aortic balloon pump (IABP). Other devices include veno-arterial (VA) ECMO, Impella, TandemHeart, CentriMag, Rotaflow, and others. Some of these devices are placed exclusively percutaneously or by vessel cutdown (the Impella and TandemHeart), and some can be placed percutaneously or surgically (IABP, VA ECMO).

This era of short-term MCSDs is still relatively young, and there is a paucity of randomized studies to definitively guide device and patient selection.[1] The following sections lay out the common indications, maintenance, weaning, complications, and outcomes of these devices based on published guidelines by the International Society for Heart and Lung Transplantation, the Society for Cardiovascular Angiography and Interventions, the American College of Cardiology Foundation, the Heart Failure Society of America, The Society of Thoracic Surgeons, and the Extracorporeal Life Support Organization as well as data from current literature.

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Last updated: August 7, 2020