De-Escalation of Support with Veno-Arterial Extracorporeal Membrane Oxygenation and Impella for Cardiogenic Shock
Year: 2017
Type: letter
Abstract: We read with interest the recently published paper by Pappalardo and colleagues1 investigating the co-implantation of Impella for left ventricular (LV) ‘venting’ in patients undergoing veno-arterial extracorporeal membrane oxygenation (VA-ECMO) for cardiogenic shock. This approach has been adopted at our institution, particularly in patients with profound LV failure. In VA-ECMO, it has been proposed that LV unloading may be impaired by increased afterload as a consequence of retrograde aortic blood flow. Various mechanisms of LV ‘venting’ have been described, including interatrial septostomy, left atrial cannulation, intra-aortic balloon pumps, and trans-aortic devices such as the Impella. The authors observed that the combination of Impella with VA-ECMO compared with VA-ECMO alone was associated with higher rates of hospital survival and successful bridges to further therapy.1 In an accompanying editorial, Lorusso asked ‘Are two crutches better than one?’.2 He highlighted that, particularly since there are other mechanisms for LV unloading, the risks of the dual systems must be taken into account, including financial costs, positional monitoring of the axial pump, and haemolysis. However, there is another potential benefit in addition to LV venting that should be considered. The described approach using an axial pump along with VA-ECMO offers an opportunity for staged de-escalation of mechanical support. Rather than going from two crutches to none, the patient can go to one. The Impella may remain in place to supplement native cardiac output as it continues to recover. The Impella flow is adjusted to provide patient-specific support depending on their intrinsic ventricular function. When the patient stabilizes, the Impella is removed and the patient transitioned to inotropes or further therapy. Intuitively, this staging is appealing, particularly when the bridge is to myocardial recovery. However, it remains to be investigated whether this staged approach is clinically beneficial. The authors note, ‘The proposed approach possibly changes the weaning process as well, as it might hasten removal from VA-ECMO as the left ventricle is still partially supported.’ It would be helpful to know from their cohort, how long the Impella remained in place after decannulation from ECMO? Also, among survivors to decannulation in the matched cohorts with and without Impella, what was the average duration of ECMO? These data would help understand whether use of Impella can enable earlier decannulation from VA-ECMO and facilitate weaning. More research is needed to determine whether this combined approach is the most efficacious and safe for managing refractory cardiogenic shock.
DOI: 10.1002/ejhf.953
Institutions: Brigham and Women's Hospital, Harvard University
Language: English
Subfield: Biomedical Engineering
Field: Engineering
Domain: Physical Sciences
Open Access status: bronze
Funder: Brigham and Women's Hospital
OpenAlex ID: W2757055550