Elsevier

Resuscitation

Volume 160, March 2021, Pages 150-157
Resuscitation

Clinical paper
Emergency veno-arterial extracorporeal membrane oxygenation (VA ECMO)-supported percutaneous interventions in refractory cardiac arrest and profound cardiogenic shock

https://doi.org/10.1016/j.resuscitation.2020.11.028Get rights and content

Abstract

Aims

We investigated the spectrum of emergency veno-arterial extracorporeal membrane oxygenation (VA ECMO)-supported interventions including percutaneous coronary intervention (PCI), transcatheter aortic valve implantation (TAVI) and invasive electrophysiology (EP).

Methods and results

Between June 2010 and February 2020, 52 consecutive patients underwent VA ECMO implantation for refractory cardiac arrest (E-CPR) and 78 for profound cardiogenic shock. Percutaneous interventions on VA ECMO included PCI (n = 29), TAVI (n = 4) and EP (n = 1). Surgical interventions were cardiac (n = 36) or non-cardiac (n = 5). During PCI, ECMO flow was maintained at 2.7 ± 1.0 L/min. Of the 40 treated lesions, 48% were located on left anterior descending and 20% on the left main artery. An average 2.0 ± 1.8 DES/patient with diameter 3.2 ± 0.5 mm and stented length 41 ± 35 mm were implanted. PCI success was 83%. TAVI was performed in 4 patients with left ventricular ejection fraction 21 ± 10% and mean aortic valve gradient 41 ± 5 mmHg. After successful valve implantation supported by 1.4 ± 0.1 L/min ECMO flow, mean gradient decreased to 11 ± 5 mmHg without significant aortic regurgitation. In one patient radiofrequency ablation of His bundle followed by permanent pacemaker implantation was performed under ECMO flow of 2.8 L/min. Overall survival to hospital discharge with good neurological recovery was 29% in E-CPR and 44% in profound cardiogenic shock.

Conclusions

Our study showed feasibility and effectiveness of VA ECMO-supported percutaneous interventions in patients with profound hemodynamic collapse.

Introduction

In patients with refractory cardiac arrest undergoing chest compressions or in patients with profound cardiogenic shock refractory to conventional treatment, emergency veno-arterial extracorporeal membrane oxygenation (VA-ECMO) provides immediate hemodynamic stabilization and buys time for possible cause-oriented and life-saving percutaneous or surgical interventions.1, 2 Due to significant technical improvements in ECMO console with fast priming, easy management and transportation as well as due to refinements in percutaneous cannulation techniques, implantation in the catheterization laboratory by skilled interventional cardiologist became feasible and safe without the presence cardiovascular surgical/perfusion team.3, 4 In the present study, we investigated the spectrum of VA ECMO-supported interventions with special emphasis on percutaneous coronary intervention (PCI), transcatheter aortic valve implantation (TAVI) and invasive electrophysiology (EP).

Section snippets

Methods

The study describes patients undergoing VA-ECMO implantation at the Center for Intensive Internal Medicine of the University Medical Center Ljubljana (Slovenia) who were enrolled into the institutional prospective VA-ECMO registry. Pediatric patients and patients with VA ECMO implantation following open heart surgery were not included. The study was approved by the National Medical Ethics Committee.

Patients were divided according to hemodynamic status at the time of VA ECMO implantation into a

Results

Between June 2010 and February 2020, 130 consecutive patients underwent VA ECMO implantation. In 52 patients undergoing E-CPR, cardiac arrest was either out-of-hospital (n = 22) or in-hospital (n = 30). While in 17 patients, cardiac arrest occurred during intervention (“rescue” E-CPR), the rest of the patients underwent “upfront” E-CPR (Fig. 1). In 78 patients with profound cardiogenic shock, VA ECMO was implanted either as “rescue” immediately after the intervention (n = 40) or “upfront” with

Discussion

In the present study, we initially described our strategy of VA ECMO support including upfront, rescue and delayed implantation. Our preliminary experience with VA ECMO-supported percutaneous interventions including PCI, TAVI and EP in a subset of actually dying patients shows feasibility, effectiveness and life-saving potential of such approach. Advantage of VA ECMO compared to other temporary left ventricular assist devices including Impella, iVAC 2L and TandemHeart is in prompt normalization

Limitations

Our study reporting a single center registry with emergency VA ECMO implantation is limited by small number of patients undergoing PCI and in particular TAVI and EP. The conclusions may therefore be regarded as preliminary. Furthermore, we currently report only hospital survival with good neurological outcome without a long term follow up including quality of life assessment.

Conclusion

Our preliminary experience shows feasibility of VA ECMO-supported percutaneous interventions including PCI, TAVI and EP in patients with refractory cardiac arrest and profound cardiogenic shock. VA ECMO provides immediate hemodynamic stability and buys time for potentially life-saving percutaneous or surgical intervention.

Impact on daily practice

Emergency VA ECMO provides immediate hemodynamic stabilization and buys time for potentially life-saving percutaneous or surgical intervention. Since modern VA ECMO may be quickly and safely implanted percutaneously in the catheterization laboratory without the presence of vascular surgeon/cardiovascular perfusion team, this strategy is nowadays feasible and effective in patients with profound hemodynamic deterioration.

Credit author statement

Each author has contributed significantly to this work and they all meet the full criteria and requirements for authorship. All authors have approved the manuscript and its submission to Resuscitation.

Financial support

Institutional grant20190051.

Conflicts of interest

The authors have no conflicts of interest to declare.

Acknowledgements

The authors are grateful to acute cardiac care physicians (Jernej Berden, Misa Fister, Alenka Golicnik, Rihard Knafelj, Ursa Mikuz, Tomaz Cankar), interventional cardiologists (Miha Cercek, Simon Terseglav, Bojan Vrtovec, Luka Lipar), cardiac electrophysiology team (Matjaz Sinkovec, Andrej Pernat) and cardiac surgeons (Matija Jelenc, Primoz Trunk) who participated during VA ECMO implantation and cardiac interventions.

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    Both authors contributed equally.

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