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Protti I, van Steenwijk MPJ, Meani P, Fresiello L, Meuwese CL, Donker DW. Left Ventricular Unloading in Extracorporeal Membrane Oxygenation: A Clinical Perspective Derived from Basic Cardiovascular Physiology. Curr Cardiol Rep 2024; 26:661-667. [PMID: 38713362 PMCID: PMC11236850 DOI: 10.1007/s11886-024-02067-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/23/2024] [Indexed: 05/08/2024]
Abstract
PURPOSE OF REVIEW To present an abridged overview of the literature and pathophysiological background of adjunct interventional left ventricular unloading strategies during veno-arterial extracorporeal membrane oxygenation (V-A ECMO). From a clinical perspective, the mechanistic complexity of such combined mechanical circulatory support often requires in-depth physiological reasoning at the bedside, which remains a cornerstone of daily practice for optimal patient-specific V-A ECMO care. RECENT FINDINGS Recent conventional clinical trials have not convincingly shown the superiority of V-A ECMO in acute myocardial infarction complicated by cardiogenic shock as compared with medical therapy alone. Though, it has repeatedly been reported that the addition of interventional left ventricular unloading to V-A ECMO may improve clinical outcome. Novel approaches such as registry-based adaptive platform trials and computational physiological modeling are now introduced to inform clinicians by aiming to better account for patient-specific variation and complexity inherent to V-A ECMO and have raised a widespread interest. To provide modern high-quality V-A ECMO care, it remains essential to understand the patient's pathophysiology and the intricate interaction of an individual patient with extracorporeal circulatory support devices. Innovative clinical trial design and computational modeling approaches carry great potential towards advanced clinical decision support in ECMO and related critical care.
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Affiliation(s)
- I Protti
- Departments of Cardiology and Intensive Care, Erasmus University Medical Center, Rotterdam, the Netherlands
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - M P J van Steenwijk
- Departments of Cardiology and Intensive Care, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - P Meani
- Maastricht University Medical Center+, Cardiothoracic Surgery, Heart and Vascular Center, Maastricht, the Netherlands
| | - L Fresiello
- Cardiovascular and Respiratory Physiology, TechMed Center, University of Twente, Hallenweg 5, 7522, NH, Enschede, The Netherlands
| | - C L Meuwese
- Departments of Cardiology and Intensive Care, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - D W Donker
- Cardiovascular and Respiratory Physiology, TechMed Center, University of Twente, Hallenweg 5, 7522, NH, Enschede, The Netherlands.
- Intensive Care Center, University Medical Center Utrecht, Utrecht, the Netherlands.
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Balder JW, Szymanski MK, van Laake LW, van der Harst P, Meuwese CL, Ramjankhan FZ, van der Meer MG, Hermens JAJM, Voskuil M, de Waal EEC, Donker DW, Oerlemans MIFJ, Kraaijeveld AO. ECPELLA as a bridge-to-decision in refractory cardiogenic shock: a single-centre experience. Neth Heart J 2024; 32:245-253. [PMID: 38713449 PMCID: PMC11143097 DOI: 10.1007/s12471-024-01872-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/11/2024] [Indexed: 05/08/2024] Open
Abstract
BACKGROUND In refractory cardiogenic shock, temporary mechanical support (tMCS) may be crucial for maintaining tissue perfusion and oxygen delivery. tMCS can serve as a bridge-to-decision to assess eligibility for left ventricular assist device (LVAD) implantation or heart transplantation, or as a bridge-to-recovery. ECPELLA is a novel tMCS configuration combining venoarterial extracorporeal membrane oxygenation with Impella. The present study presents the clinical parameters, outcomes, and complications of patients supported with ECPELLA. METHODS All patients supported with ECPELLA at University Medical Centre Utrecht between December 2020 and August 2023 were included. The primary outcome was 30-day mortality, and secondary outcomes were LVAD implantation/heart transplantation and safety outcomes. RESULTS Twenty patients with an average age of 51 years, and of whom 70% were males, were included. Causes of cardiogenic shock were acute heart failure (due to acute coronary syndrome, myocarditis, or after cardiac surgery) or chronic heart failure, respectively 70 and 30% of cases. The median duration of ECPELLA support was 164 h (interquartile range 98-210). In 50% of cases, a permanent LVAD was implanted. Cardiac recovery within 30 days was seen in 30% of cases and 30-day mortality rate was 20%. ECPELLA support was associated with major bleeding (40%), haemolysis (25%), vascular complications (30%), kidney failure requiring replacement therapy (50%), and Impella failure requiring extraction (15%). CONCLUSION ECPELLA can be successfully used as a bridge to LVAD implantation or as a bridge-to-recovery in patients with refractory cardiogenic shock. Despite a significant number of complications, 30-day mortality was lower than observed in previous cohorts.
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Affiliation(s)
- Jan-Willem Balder
- Department of Cardiology, University Medical Centre Utrecht, Utrecht, The Netherlands.
| | - Mariusz K Szymanski
- Department of Cardiology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Linda W van Laake
- Department of Cardiology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Pim van der Harst
- Department of Cardiology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Christiaan L Meuwese
- Department of Cardiology, Erasmus Medical Centre, Rotterdam, The Netherlands
- Department of Intensive Care, Erasmus Medical Centre, Rotterdam, The Netherlands
| | - Faiz Z Ramjankhan
- Department of Cardiothoracic Surgery, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Manon G van der Meer
- Department of Cardiology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Jeannine A J M Hermens
- Department of Intensive Care, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Michiel Voskuil
- Department of Cardiology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Eric E C de Waal
- Department of Anaesthesiology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Dirk W Donker
- Department of Intensive Care, University Medical Centre Utrecht, Utrecht, The Netherlands
- Cardiovascular and Respiratory Physiology, Tech Med Centre, University of Twente, Enschede, The Netherlands
| | | | - Adriaan O Kraaijeveld
- Department of Cardiology, University Medical Centre Utrecht, Utrecht, The Netherlands
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Ali S, Meuwese CL, Moors XJR, Donker DW, van de Koolwijk AF, van de Poll MCG, Gommers D, Dos Reis Miranda D. Extracorporeal cardiopulmonary resuscitation for refractory cardiac arrest: an overview of current practice and evidence. Neth Heart J 2024; 32:148-155. [PMID: 38376712 PMCID: PMC10951133 DOI: 10.1007/s12471-023-01853-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/05/2023] [Indexed: 02/21/2024] Open
Abstract
Cardiac arrest (CA) is a common and potentially avoidable cause of death, while constituting a substantial public health burden. Although survival rates for out-of-hospital cardiac arrest (OHCA) have improved in recent decades, the prognosis for refractory OHCA remains poor. The use of veno-arterial extracorporeal membrane oxygenation during cardiopulmonary resuscitation (ECPR) is increasingly being considered to support rescue measures when conventional cardiopulmonary resuscitation (CPR) fails. ECPR enables immediate haemodynamic and respiratory stabilisation of patients with CA who are refractory to conventional CPR and thereby reduces the low-flow time, promoting favourable neurological outcomes. In the case of refractory OHCA, multiple studies have shown beneficial effects in specific patient categories. However, ECPR might be more effective if it is implemented in the pre-hospital setting to reduce the low-flow time, thereby limiting permanent brain damage. The ongoing ON-SCENE trial might provide a definitive answer regarding the effectiveness of ECPR. The aim of this narrative review is to present the most recent literature available on ECPR and its current developments.
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Affiliation(s)
- Samir Ali
- Department of Intensive Care, Erasmus University Medical Centre, Rotterdam, The Netherlands.
- Department of Anaesthesiology, Erasmus Medical Centre, Rotterdam, The Netherlands.
- Ministry of Defence, Royal Netherlands Air Force, Breda, The Netherlands.
| | - Christiaan L Meuwese
- Department of Intensive Care, Erasmus University Medical Centre, Rotterdam, The Netherlands
- Department of Cardiology, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Xavier J R Moors
- Department of Anaesthesiology, Erasmus Medical Centre, Rotterdam, The Netherlands
- Helicopter Emergency Medical Services, Trauma Centre Zuid-West Nederland, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Dirk W Donker
- Cardiovascular and Respiratory Physiology, Faculty of Science and Technology, University of Twente, Enschede, The Netherlands
- Department of Intensive Care, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Anina F van de Koolwijk
- Department of Intensive Care, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Marcel C G van de Poll
- Department of Intensive Care, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Diederik Gommers
- Department of Intensive Care, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Dinis Dos Reis Miranda
- Department of Intensive Care, Erasmus University Medical Centre, Rotterdam, The Netherlands
- Helicopter Emergency Medical Services, Trauma Centre Zuid-West Nederland, Erasmus University Medical Centre, Rotterdam, The Netherlands
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Adriaansen EJM, Hermens JAJ, Broome M, Pladet L, Dubois E, Donker DW, Meuwese CL. Cardiac tamponade during venoarterial extracorporeal membrane oxygenation: a case report. J Med Case Rep 2023; 17:50. [PMID: 36755312 PMCID: PMC9909901 DOI: 10.1186/s13256-022-03741-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Accepted: 12/27/2022] [Indexed: 02/10/2023] Open
Abstract
BACKGROUND Cardiac tamponade may present with very different signs and clinical consequences in patients who are supported with venoarterial extracorporeal membrane oxygenation. Failure to recognize cardiac tamponade in this setting can cause failure to wean from venoarterial extracorporeal membrane oxygenation, and even lead to death. CASE PRESENTATION We present a 44-year-old Caucasian female in whom cardiac tamponade manifested as venoarterial extracorporeal membrane oxygenation weaning failure. After discovering the contribution of cardiac tamponade, it was possible to wean the patient from venoarterial extracorporeal membrane oxygenation support. No clear signs of cardiac tamponade had existed beforehand. CONCLUSIONS The diagnosis of cardiac tamponade can be very challenging in venoarterial extracorporeal membrane oxygenation supported patients due to (patho)physiological particularities related to the parallel blood flow.
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Affiliation(s)
- E. J. M. Adriaansen
- grid.7692.a0000000090126352Department of Intensive Care, Utrecht University Medical Center, Utrecht, The Netherlands
| | - J. A. J. Hermens
- grid.7692.a0000000090126352Department of Intensive Care, Utrecht University Medical Center, Utrecht, The Netherlands
| | - M. Broome
- grid.24381.3c0000 0000 9241 5705ECMO Department, Karolinska University Hospital, Stockholm, Sweden ,grid.24381.3c0000 0000 9241 5705Division of Anesthesia and Intensive Care, Department of Physiology and Pharmacology, Karolinska University Hospital, Stockholm, Sweden
| | - L. Pladet
- grid.7692.a0000000090126352Department of Intensive Care, Utrecht University Medical Center, Utrecht, The Netherlands
| | - E. Dubois
- grid.5645.2000000040459992XDepartment of Intensive Care, Erasmus Medical Center, Rotterdam, The Netherlands ,grid.5645.2000000040459992XDepartment of Cardiology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - D. W. Donker
- grid.7692.a0000000090126352Department of Intensive Care, Utrecht University Medical Center, Utrecht, The Netherlands ,grid.6214.10000 0004 0399 8953Cardiovascular and Respiratory Physiology Group, TechMed Centre, Faculty of Science and Technology, University of Twente, Enschede, The Netherlands
| | - C. L. Meuwese
- grid.5645.2000000040459992XDepartment of Intensive Care, Erasmus Medical Center, Rotterdam, The Netherlands ,grid.5645.2000000040459992XDepartment of Cardiology, Erasmus Medical Center, Rotterdam, The Netherlands
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Meuwese CL, Brodie D, Donker DW. The ABCDE approach to difficult weaning from venoarterial extracorporeal membrane oxygenation. Crit Care 2022; 26:216. [PMID: 35841052 PMCID: PMC9284848 DOI: 10.1186/s13054-022-04089-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Accepted: 07/05/2022] [Indexed: 11/10/2022] Open
Abstract
AbstractVenoarterial extracorporeal membrane oxygenation (VA ECMO) has been increasingly applied in patients with cardiogenic shock in recent years. Nevertheless, many patients cannot be successfully weaned from VA ECMO support and 1-year mortality remains high. A systematic approach could help to optimize clinical management in favor of weaning by identifying important factors in individual patients. Here, we provide an overview of pivotal factors that potentially prevent successful weaning of VA ECMO. We present this through a rigorous approach following the relatable acronym ABCDE, in order to facilitate widespread use in daily practice.
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van der Wal PS, Kraaijeveld AO, van der Heijden JJ, van Laake LW, Platenkamp M, de Heer LM, Braithwaite SA, van Eijk M, Hermens J, Cremer OL, Donker DW, Meuwese CL. Initiation of veno-arterial extracorporeal membrane oxygenation (VA-ECMO) for cardiogenic shock during out of hours versus working hours is not associated with increased mortality. Int J Artif Organs 2022; 45:301-308. [PMID: 35139685 DOI: 10.1177/03913988211073344] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Initiation of veno-arterial (VA) Extracorporeal Membrane Oxygenator (ECMO) is associated with severe complications. It is unknown whether these adverse consequences occur more often after initiations during out of hours service compared to working hours. METHODS All patients receiving VA-ECMO for cardiogenic shock between 2009 and 2020 were categorized into a working hours group (between 8 am and 5 pm on weekdays) and an out of hours service group (between 5 pm and 8 am, or between Friday 5 pm and Monday 8 am). Primary outcome was all-cause mortality at 30 days. Secondary outcomes included vascular complications (including limb ischemia and/or bleeding), bloodstream infections and length of ICU stay. Propensity scores were used to adjust for potential confounding effects. RESULTS Among 250 patients (median (IQR) age 56 (42-64) years) receiving VA-ECMO (median duration 3.5 (1.0-9.0) days), 160 (64%) runs were initiated between 5 pm and 8 am whereas the remainder (36%) started during working hours. Characteristic did not differ between the working hours- and out of hours-group. By day 30, 37 (41.1%), and 68 (42.5%) patients in either group had died, respectively (p = 0.831). VA-ECMO support duration and length of stay on the ICU did not differ significantly in both crude and adjusted analyses. More complications occurred during out of hours service (p = 0.039). CONCLUSIONS Out of hours- versus working hours-initiation of VA-ECMO for cardiogenic shock was not associated with higher mortality, longer VA-ECMO support duration, or longer length of stay on the intensive care. Vascular complications were more common in the out of hours group.
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Affiliation(s)
- P S van der Wal
- Department of Intensive Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - A O Kraaijeveld
- Department of Cardiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - J J van der Heijden
- Department of Intensive Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - L W van Laake
- Department of Cardiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - M Platenkamp
- Department of Intensive Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - L M de Heer
- Department of Intensive Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - S A Braithwaite
- Department of Cardioanesthesiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Mmj van Eijk
- Department of Intensive Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Jaj Hermens
- Department of Intensive Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - O L Cremer
- Department of Intensive Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - D W Donker
- Department of Intensive Care, University Medical Center Utrecht, Utrecht, The Netherlands.,Cardiovascular and Respiratory Physiology Group, TechMed Centre, Faculty of Science and Technology, University of Twente, Enschede, The Netherlands
| | - C L Meuwese
- Departments of Intensive Care and Cardiology, Erasmus Medical Center, Rotterdam, The Netherlands
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