Protecting the Vulnerable Left Ventricle
2019; Lippincott Williams & Wilkins; Volume: 12; Issue: 11 Linguagem: Inglês
10.1161/circheartfailure.119.006581
ISSN1941-3297
AutoresNavin K. Kapur, Carlos D. Davila, Haval Chweich,
Tópico(s)Cardiac Arrest and Resuscitation
ResumoHomeCirculation: Heart FailureVol. 12, No. 11Protecting the Vulnerable Left Ventricle Free AccessEditorialPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessEditorialPDF/EPUBProtecting the Vulnerable Left VentricleThe Art of Unloading With VA-ECMO Navin K. Kapur, MD, Carlos D. Davila, MD and Haval Chweich, MD Navin K. KapurNavin K. Kapur Correspondence to: Navin K. Kapur, MD, The Cardiovascular Center; Tufts Medical Center, 800 Washington St, Box No. 80, Boston, MA 02111. Email E-mail Address: [email protected] Department of Medicine; Division of Cardiology, Tufts Medical Center, The CardioVascular Center, Boston, MA. , Carlos D. DavilaCarlos D. Davila Department of Medicine; Division of Cardiology, Tufts Medical Center, The CardioVascular Center, Boston, MA. and Haval ChweichHaval Chweich Department of Medicine; Division of Cardiology, Tufts Medical Center, The CardioVascular Center, Boston, MA. Originally published13 Nov 2019https://doi.org/10.1161/CIRCHEARTFAILURE.119.006581Circulation: Heart Failure. 2019;12:e006581This article is a commentary on the followingOptimal Strategy and Timing of Left Ventricular Venting During Veno-Arterial Extracorporeal Life Support for Adults in Cardiogenic ShockSee Article by Al-Fares et alOriginally introduced by Hill and Bartlett in the 1970s as a method to support patients with respiratory failure, extracorporeal membrane oxygenation (ECMO) use has grown exponentially over the past few decades.1 Veno-arterial ECMO (VA-ECMO) is commonly used to support patients with cardiac arrest, circulatory collapse, or cardio-respiratory failure by withdrawing deoxygenated venous blood and pumping oxygenated blood into the arterial circulation. Centrally placed VA-ECMO refers to surgical implantation of conduit grafts directly to the right atrium (inflow) and aorta (outflow), while peripheral VA-ECMO refers to percutaneously deployed inflow and outflow cannulas into the systemic circulation. Inflow cannulas are often positioned in the superior vena cava across the right atrium using a large multi-staged venous cannula. Outflow cannulas can be positioned in the femoral or subclavian arteries. Vascular grafts surgically anastomosed to the subclavian or femoral arteries can be used in lieu of outflow cannulas to return oxygenated blood back to the arterial system.VA-ECMO displaces blood from a large venous reservoir into the arterial circulation. If a patient has low volume in the venous system (ie, low right heart filling pressures), then VA-ECMO may reduce total cardiac preload and thereby reduce left ventricle (LV) volume. However, most patients with cardiogenic shock have concomitant venous congestion. By pressurizing the arterial system, VA-ECMO increases systemic blood pressure. If native LV function is preserved, LV systolic pressure will increase with minor changes in LV diastolic pressure as the native heart actively recruits more contractility to overcome any increase in ventricular afterload. However, if native LV function is compromised, both LV systolic and diastolic pressures will increase as the vulnerable LV fails to pump effectively against increased afterload imposed by an extracorporeal pump and pressurized arterial tree. This increase in LV afterload increases LV and left atrial wall stress, myocardial oxygen consumption, and may worsen pulmonary congestion, acute lung injury and pulmonary hemorrhage, thereby worsening cardio-pulmonary function and initiating a vicious cycle of mechanically driven injury.2,3Predicting a patient's risk of developing VA-ECMO associated ventricular load remains challenging. A recent in silico analysis of Starling Curves identified that reduced ejection fraction and a greater magnitude of change in mean arterial pressure after initiation of VA-ECMO may identify patients at risk for pump-related pulmonary congestion.4 Hemodynamic evaluation and monitoring around the time of VA-ECMO initiation is of paramount importance to manage this problem.To mitigate the impact of VA-ECMO on LV load, several ventricular decompression or venting strategies are commonly employed (Table). Pharmacological support with inotropes should be considered but may increase ventricular work and promote myocardial ischemia or arrhythmias. Surgically placed central VA-ECMO requires implantation of an additional inflow conduit from the left atrium or left ventricle into the inflow segment of the VA-ECMO circuit to unload the LV. For peripherally cannulated VA-ECMO, venting strategies include atrial septostomy, left atrial cannulation (via trans-septal puncture), pulmonary artery cannulation, or employment of a second mechanical support device such as an intraaortic balloon pump or trans-valvular axial flow pump (Impella 2.5, CP, or 5.0). Advantages and disadvantages of these approaches are detailed in Table.Table. Left Ventricular Venting Strategies for Veno-Arterial Extracorporeal Membrane OxygenationMechanismAdvantagesDisadvantagesPharmacological venting InotropesIncrease LV contractilityNoninvasiveIncreases LV work, myocardial ischemia, and propensity for arrhythmiasPassive venting Atrial septostomyAllows for passive shunting of blood from the left to right atriumNo intracardiac device requiredTrans-septal puncture required; limited durability; cannot regulate flowVenting with central (surgical) VA-ECMO Surgical cannulation of the left atrium, pulmonary vein, or left ventricleDisplaces blood from the left atrium or ventricle into the inflow segment of VA-ECMO (reduces LV preload)High flow capacity and durableRequires surgical access; risk of cardiac damage and arrhythmiasVenting with peripheral (non-surgical) VA-ECMO Trans-septal inflow catheter or cannulaDisplaces blood from the left atrium into the inflow segment of VA-ECMO (reduces LV preload)High flow capacity and magnitude of flow can be regulatedTrans-septal puncture required; limited durability; risk of cannula migration and vascular injury Pulmonary artery cannulaDisplaces blood from the pulmonary artery into the inflow segment of VA-ECMO (partially reduces LV preload)High flow capacity and magnitude of flow can be regulatedRequires cannulation of the pulmonary artery via the femoral vein; limited efficacy and durability; risk of cannula migration and vascular injury Intraaortic balloon pumpReduces left ventricular afterloadMinimally invasive (8–9Fr sheath)Partial unloading effect; fails with tachyarrhythmias; risk of vascular injury Impella trans-aortic axial flow pumpDisplaces blood from the left ventircle into the aortaNonsurgical; direct LV unloading; good for de-escalation from VA-ECMO to isolated LV support13–14 French sheath or surgical graft required (for Impella 5.0); risk of hemolysis, aortic root or LV thrombus formation, North-South Syndrome; vascular injuryLV indicates left ventricular; and VA-ECMO, veno-arterial extracorporeal membrane oxygenation.In this issue of Circulation: Heart Failure, Al-Fares et al5 performed a meta-analysis of 62 observational studies including 7995 patients receiving either central or peripherally placed VA-ECMO among whom 3458 had a concomitant LV vent and 4537 did not. This represents one of the largest analysis of LV venting reported to date. The authors report that weaning off VA-ECMO and 30-day mortality was lower among patients who received concomitant LV venting and further report that initiation of LV venting within 12 hours of VA-ECMO initiation was associated with better outcomes. A nonsignificant trend towards improved in-hospital and long-term (up to 6 months) mortality was observed. Most cases studied were vented with an intraaortic balloon pump with far fewer cases employing Impella pumps or surgical venting. The authors report no major increase in adverse events associated with venting, but identify hemolysis, increased renal injury, bleeding and vascular injury as potential risks. This type of analysis can be particularly challenging for several reasons including significant heterogeneity in clinical practice with regards to device escalation, timing of LV venting, technical approaches, and management of various venting strategies.One of the most sobering findings from this study is the in-hospital mortality rate of 60% among patients receiving VA-ECMO support. This observation is consistent with several contemporary studies showing that despite increasing use, clinical outcomes associated with VA-ECMO for cardiogenic shock remain poor.6–8 A recent German analysis identified a >30-fold increase in the use of VA-ECMO between 2007 and 2015, however overall 30-day mortality remained unchanged around 60%.8Several explanations may account for these poor outcomes. First, patient selection for acute mechanical circulatory support (MCS) is a major determinant of clinical outcomes. Increased age, cardiac arrest, neurological injury, significant comorbidities, and the lack of a clear exit strategy are among the elements that may dictate survival independent of which acute MCS strategy is employed. Second, early identification and initiation of acute MCS is required to provide hemodynamic stabilization before end-organ injury becomes irreversible. Third, the lack of tailored shock management algorithms promotes heterogeneity in clinical practice. Recent data suggests that implementation of a shock-treatment algorithm that promotes hemodynamic assessment and early initiation of acute MCS can improve shock survival particularly among patients with acute myocardial infarction.9,10 The combination of treatment algorithms and the development of a common classification system for cardiogenic shock may enhance communication regarding the severity of shock and improve clinical management and future investigation of this complex problem.The study by Al-Fares et al5 now highlights the need for specific algorithms to optimize LV venting with VA-ECMO. In this analysis, intraaortic balloon pump was the most common venting strategy and was associated with improved outcomes. However, several studies have also shown improved outcomes with the combination of VA-ECMO with Impella.11,12 Development of LV venting algorithms will be particularly challenging given that many patients will have already received intraaortic balloon pump or Impella support before initiation of VA-ECMO and as a result LV venting may be dictated by the device escalation strategy in place. Venting algorithms will also have to account for an increased risk of complications associated with each approach including bleeding, vascular injury, hemolysis, acute kidney injury, thrombosis, and stroke. The impact of acute MCS on each of these complications remains poorly understood. Finally, management of VA-ECMO with an LV vent must be tailored to each strategy. For example, no studies have determined the best approach to optimizing flow through an Impella device in the setting of VA-ECMO. If substantial lung injury exists, avoiding high flow through an Impella device may decrease the risk of North-South Syndrome where de-oxygenated blood is ejected into the aortic arch towards the brain. In contrast, if a patient has severe LV impairment and pulmonary congestion, increasing Impella flow to unload the LV may be required. Recognizing that these pumps do not work in conflict, but rather in confluence with each other, may help optimize device management.VA-ECMO remains a critical component of any cardiogenic shock program. However, clinical outcomes with VA-ECMO are consistently poor for cardiogenic shock irrespective of the underlying cause.6–8 No randomized controlled trial data supporting the use of VA-ECMO for cardiogenic shock exist. The recently proposed Euro-Shock Trial (URL: http://www.clinicaltrials.gov. Unique identifier: NCT03813134) will explore the clinical utility of VA-ECMO in the setting of acute myocardial infarction and cardiogenic shock.13 Within the study design, an algorithm for LV venting should be considered. Studies like the current report by Al-Fares et al5 suggest that VA-ECMO may provide circulatory support but requires concomitant approaches to provide cardiac support (ie, unloading) and to protect the vulnerable LV from injury mediated by mechanically increased LV afterload. More studies are required to improve risk prediction and management of acute MCS for cardiogenic shock.Sources of FundingNone.DisclosuresDr Kapur has received consulting and speaking honoraria from Abbott, Abiomed, Boston Scientific, LivaNova, Maquet; Medtronic, MDStart, and Precardia. He receives research funding from Abbott, Abiomed, Boston Scientific, and MDStart. Dr Chweich has received consulting and speaking honoraria from Abiomed. The other authors report no conflicts.FootnotesFor Sources of Funding and Disclosures, see page 3.The opinions expressed in this article are not necessarily those of the editors or of the American Heart Association.Correspondence to: Navin K. Kapur, MD, The Cardiovascular Center; Tufts Medical Center, 800 Washington St, Box No. 80, Boston, MA 02111. Email [email protected]orgReferences1. Zapol WM, Snider MT, Hill JD, Fallat RJ, Bartlett RH, Edmunds LH, Morris AH, Peirce EC, Thomas AN, Proctor HJ, Drinker PA, Pratt PC, Bagniewski A, Miller RG. Extracorporeal membrane oxygenation in severe acute respiratory failure. A randomized prospective study.JAMA. 1979; 242:2193–2196. doi: 10.1001/jama.242.20.2193CrossrefMedlineGoogle Scholar2. Burkhoff D, Sayer G, Doshi D, Uriel N. Hemodynamics of mechanical circulatory support.J Am Coll Cardiol. 2015; 66:2663–2674. doi: 10.1016/j.jacc.2015.10.017CrossrefMedlineGoogle Scholar3. Rao P, Khalpey Z, Smith R, Burkhoff D, Kociol RD. Venoarterial extracorporeal membrane oxygenation for cardiogenic shock and cardiac arrest.Circ Heart Fail. 2018; 11:e004905. doi: 10.1161/CIRCHEARTFAILURE.118.004905LinkGoogle Scholar4. Dickstein ML. The starling relationship and veno-arterial ECMO: ventricular distension explained.ASAIO J. 2018; 64:497–501. doi: 10.1097/MAT.0000000000000660CrossrefMedlineGoogle Scholar5. Al-Fares AA, Randhawa VK, Englesakis M, McDonald MA, Nagpal AD, Estep JD, Soltesz EG, Fan E. 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; 12:e006486. doi: 10.1161/CIRCHEARTFAILURE.119.006486LinkGoogle Scholar6. Garan AR, Malick WA, Habal M, Topkara VK, Fried J, Masoumi A, Hasan AK, Karmpaliotis D, Kirtane A, Yuzefpolskaya M, Farr M, Naka Y, Burkhoff D, Colombo PC, Kurlansky P, Takayama H, Takeda K. Predictors of survival for patients with acute decompensated heart failure requiring extra-corporeal membrane oxygenation therapy.ASAIO J. 2019; 65:781–787. doi: 10.1097/MAT.0000000000000898CrossrefMedlineGoogle Scholar7. Shah M, Patnaik S, Patel B, Ram P, Garg L, Agarwal M, Agrawal S, Arora S, Patel N, Wald J, Jorde UP. Trends in mechanical circulatory support use and hospital mortality among patients with acute myocardial infarction and non-infarction related cardiogenic shock in the United States.Clin Res Cardiol. 2018; 107:287–303. doi: 10.1007/s00392-017-1182-2CrossrefMedlineGoogle Scholar8. Becher PM, Schrage B, Sinning CR, Schmack B, Fluschnik N, Schwarzl M, Waldeyer C, Lindner D, Seiffert M, Neumann JT, Bernhardt AM, Zeymer U, Thiele H, Reichenspurner H, Blankenberg S, Twerenbold R, Westermann D. Venoarterial extracorporeal membrane oxygenation for cardiopulmonary support.Circulation. 2018; 138:2298–2300. doi: 10.1161/CIRCULATIONAHA.118.036691LinkGoogle Scholar9. Basir MB, Kapur NK, Patel K, Salam MA, Schreiber T, Kaki A, Hanson I, Almany S, Timmis S, Dixon S, Kolski B, Todd J, Senter S, Marso S, Lasorda D, Wilkins C, Lalonde T, Attallah A, Larkin T, Dupont A, Marshall J, Patel N, Overly T, Green M, Tehrani B, Truesdell AG, Sharma R, Akhtar Y, McRae T, O'Neill B, Finley J, Rahman A, Foster M, Askari R, Goldsweig A, Martin S, Bharadwaj A, Khuddus M, Caputo C, Korpas D, Cawich I, McAllister D, Blank N, Alraies MC, Fisher R, Khandelwal A, Alaswad K, Lemor A, Johnson T, Hacala M, O'Neill WW; National Cardiogenic Shock Initiative Investigators. Improved outcomes associated with the use of shock protocols: updates from the National Cardiogenic Shock Initiative.Catheter Cardiovasc Interv. 2019; 93:1173–1183. doi: 10.1002/ccd.28307MedlineGoogle Scholar10. Tehrani BN, Truesdell AG, Sherwood MW, Desai S, Tran HA, Epps KC, Singh R, Psotka M, Shah P, Cooper LB, Rosner C, Raja A, Barnett SD, Saulino P, deFilippi CR, Gurbel PA, Murphy CE, O'Connor CM. Standardized team-based care for cardiogenic shock.J Am Coll Cardiol. 2019; 73:1659–1669. doi: 10.1016/j.jacc.2018.12.084CrossrefMedlineGoogle Scholar11. Patel SM, Lipinski J, Al-Kindi SG, Patel T, Saric P, Li J, Nadeem F, Ladas T, Alaiti A, Phillips A, Medalion B, Deo S, Elgudin Y, Costa MA, Osman MN, Attizzani GF, Oliveira GH, Sareyyupoglu B, Bezerra HG. 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. doi: 10.1097/MAT.0000000000000767CrossrefMedlineGoogle Scholar12. Schrage B, Burkhoff D, Rübsamen N, Becher PM, Schwarzl M, Bernhardt A, Grahn H, Lubos E, Söffker G, Clemmensen P, Reichenspurner H, Blankenberg S, Westermann D. Unloading of the left ventricle during venoarterial extracorporeal membrane oxygenation therapy in cardiogenic shock.JACC Heart Fail. 2018; 6:1035–1043. doi: 10.1016/j.jchf.2018.09.009CrossrefMedlineGoogle Scholar13. U.S. National Library of Medicine. Testing the Value of Novel Strategy and Its Cost Efficacy in Order to Improve the Poor Outcomes in Cardiogenic Shock (EUROSHOCK).https://clinicaltrials.gov/ct2/show/NCT03813134. Accessed October 17, 2019.Google Scholar Previous Back to top Next FiguresReferencesRelatedDetailsCited ByGeller B, Sinha S, Kapur N, Bakitas M, Balsam L, Chikwe J, Klein D, Kochar A, Masri S, Sims D, Wong G, Katz J and van Diepen S (2022) Escalating and De-escalating Temporary Mechanical Circulatory Support in Cardiogenic Shock: A Scientific Statement From the American Heart Association, Circulation, 146:6, (e50-e68), Online publication date: 9-Aug-2022. Jiang M, Xie X, Cao F and Wang Y (2021) Mitochondrial Metabolism in Myocardial Remodeling and Mechanical Unloading: Implications for Ischemic Heart Disease, Frontiers in Cardiovascular Medicine, 10.3389/fcvm.2021.789267, 8 RALI A, HALL E, DIETER R, RANKA S, CIVITELLO A, BACCHETTA M, SHAH A, SCHLENDORF K, LINDENFELD J and CHATTERJEE S (2021) Left Ventricular Unloading During Extracorporeal Life Support: Current Practice, Journal of Cardiac Failure, 10.1016/j.cardfail.2021.12.002, Online publication date: 1-Dec-2021. Zarragoikoetxea I, Pajares A, Moreno I, Porta J, Koller T, Cegarra V, Gonzalez A, Eiras M, Sandoval E, Sarralde J, Quintana-Villamandos B and Vicente Guillén R (2021) Documento de consenso SEDAR/SECCE sobre el manejo de ECMO, Cirugía Cardiovascular, 10.1016/j.circv.2021.06.006, 28:6, (332-352), Online publication date: 1-Nov-2021. Zarragoikoetxea I, Pajares A, Moreno I, Porta J, Koller T, Cegarra V, Gonzalez A, Eiras M, Sandoval E, Aurelio Sarralde J, Quintana-Villamandos B and Vicente Guillén R (2021) SEDAR/SECCE ECMO management consensus document, Revista Española de Anestesiología y Reanimación (English Edition), 10.1016/j.redare.2020.12.002, 68:8, (443-471), Online publication date: 1-Oct-2021. Zarragoikoetxea I, Pajares A, Moreno I, Porta J, Koller T, Cegarra V, Gonzalez A, Eiras M, Sandoval E, Aurelio Sarralde J, Quintana-Villamandos B and Vicente Guillén R (2021) Documento de consenso SEDAR/SECCE sobre el manejo de ECMO, Revista Española de Anestesiología y Reanimación, 10.1016/j.redar.2020.12.011, 68:8, (443-471), Online publication date: 1-Oct-2021. Abraham J, BLUMER V, BURKHOFF D, PAHUJA M, SINHA S, ROSNER C, VOROVICH E, GRAFTON G, BAGNOLA A, HERNANDEZ-MONTFORT J and KAPUR N (2021) Heart Failure-Related Cardiogenic Shock: Pathophysiology, Evaluation and Management Considerations, Journal of Cardiac Failure, 10.1016/j.cardfail.2021.08.010, 27:10, (1126-1140), Online publication date: 1-Oct-2021. Henry T, Tomey M, Tamis-Holland J, Thiele H, Rao S, Menon V, Klein D, Naka Y, Piña I, Kapur N and Dangas G (2021) Invasive Management of Acute Myocardial Infarction Complicated by Cardiogenic Shock: A Scientific Statement From the American Heart Association, Circulation, 143:15, (e815-e829), Online publication date: 13-Apr-2021. Kapur N, Hirst C, Davila C and Garcia R (2020) Single stick access using a VA‐ECMO arterial return cannula for coronary intervention in cardiogenic shock, Catheterization and Cardiovascular Interventions, 10.1002/ccd.29073, 97:5, Online publication date: 1-Apr-2021. Tschöpe C, Spillmann F, Potapov E, Faragli A, Rapis K, Nelki V, Post H, Schmidt G and Alogna A (2021) The "TIDE"-Algorithm for the Weaning of Patients With Cardiogenic Shock and Temporarily Mechanical Left Ventricular Support With Impella Devices. A Cardiovascular Physiology-Based Approach, Frontiers in Cardiovascular Medicine, 10.3389/fcvm.2021.563484, 8 Tehrani B, Basir M and Kapur N (2020) Acute myocardial infarction and cardiogenic shock: Should we unload the ventricle before percutaneous coronary intervention?, Progress in Cardiovascular Diseases, 10.1016/j.pcad.2020.09.001, 63:5, (607-622), Online publication date: 1-Sep-2020. Swain L, Reyelt L, Bhave S, Qiao X, Thomas C, Zweck E, Crowley P, Boggins C, Esposito M, Chin M, Karas R, O'Neill W and Kapur N (2020) Transvalvular Ventricular Unloading Before Reperfusion in Acute Myocardial Infarction, Journal of the American College of Cardiology, 10.1016/j.jacc.2020.06.031, 76:6, (684-699), Online publication date: 1-Aug-2020. Related articlesOptimal Strategy and Timing of Left Ventricular Venting During Veno-Arterial Extracorporeal Life Support for Adults in Cardiogenic ShockAbdulrahman A. Al-Fares, et al. Circulation: Heart Failure. 2019;12 November 2019Vol 12, Issue 11 Advertisement Article InformationMetrics © 2019 American Heart Association, Inc.https://doi.org/10.1161/CIRCHEARTFAILURE.119.006581PMID: 31718318 Originally publishedNovember 13, 2019 Keywordscardiogenic shockventricular assist devicehemodynamicsheart failurePDF download Advertisement SubjectsCardiopulmonary Resuscitation and Emergency Cardiac CareHeart FailureMyocardial Infarction
Referência(s)