Veno-arterial extracorporeal membrane oxygenation for high-risk cardiac catheterisation procedures

Use of extracorporeal membrane oxygenation as a bridge to transcatheter aortic valve replacement in a patient with aortic stenosis and severe coronary artery disease: a case report

Background

Patients with severe aortic stenosis (AS) often present with multiple comorbidities and suffer from critical coronary artery disease (CAD). Transcatheter aortic valve replacement (TAVR) has become the therapy of choice for moderate to high-risk patients. Venoarterial extracorporeal membrane oxygenation (v-a-ECMO) offers the possibility of temporary cardiac support to manage life-threatening critical situations.

Case summary

Here, we describe the management of a patient with severe AS and CAD with impaired left ventricular ejection fraction (LVEF). We used v-a-ECMO as an emergency strategy in cardiogenic shock during a high-risk coronary intervention to stabilize the patient, and as a further bridge to TAVR.

Discussion

Very high-risk patients with severe AS are unlikely to tolerate the added risk of surgical aortic valve replacement. Using ECMO may help them to benefit from TAVR as the only treatment option available.

In-hospital outcomes after emergency or prophylactic veno-arterial extracorporeal membrane oxygenation during transcatheter aortic valve implantation: a comprehensive review of the literature

Veno-arterial extracorporeal membrane oxygenation (V-A ECMO) has been used to deal with life-threatening complications as well as back-up or active cardiovascular support during high-risk procedures in patients undergoing transcatheter aortic valve implantation (TAVI). PubMed and MEDLINE electronic databases were searched in order to identify studies with emergency or prophylactic V-A ECMO application in association with TAVI procedures. From November 2012 to November 2017, 14 relevant studies were identified that included 5,115 TAVI patients of whom 102 (2%) required V-A ECMO (22 prophylactically, 66 as an emergency and 14 without a reported indication). The reason for emergency V-A ECMO institution was detailed in 64 patients: left ventricle free wall rupture (n = 14), haemodynamic instability (n = 12), ventricular arrhythmias (n = 7), aortic annulus rupture (n = 6), coronary obstruction (n = 6), low left ventricular output (ejection fraction <35%) (n = 5), uncontrollable bleeding (n = 5), severe aortic regurgitation (n = 4), prosthesis embolisation (n = 3), aortic dissection (n = 1) and respiratory failure (n = 1). Femoral arterial and vein cannulation was the most common access technique for V-A ECMO institution. Major bleeding (n = 7) and vascular access complications (n = 7) were reported after ECMO institution. The overall in-hospital survival was 73% (61% in the emergency vs. 100% in the prophylactic group). V-A ECMO support should be available at any centre performing TAVI and provides effective mechanical circulatory support in an emergency setting. We present an algorithm to aid decisions about prophylactic circulatory assistance with V-A ECMO and it should form part of the heart team discussion before a TAVI procedure is undertaken.

New horizons of non-emergent use of extracorporeal membranous oxygenator support

The expansion of the extra corporeal membrane oxygenation (ECMO) use and its indication is strikingly increased in the past few years. ECMO use expanded to lung transplantation, difficult general thoracic resections, transcatheter aortic valve replacement (TAVR) and LVAD implantation. Here we will discuss the indications and the outcomes of non-emergent use of ECMO.

Cannulation strategies for percutaneous extracorporeal membrane oxygenation in adults

Extracorporeal membrane oxygenation (ECMO) has revolutionized treatment of severe isolated or combined failure of lung and heart. Due to remarkable technical development the frequency of use is growing fast, with increasing adoption by interventional cardiologists independent of cardiac surgery. Nevertheless, ECMO support harbors substantial risk such as bleeding, thromboembolic events and infection. Percutaneous ECMO circuits usually comprise cannulation of two large vessels ('dual' cannulation), either veno-venous for respiratory and veno-arterial for circulatory support. Recently experienced centers apply more advanced strategies by cannulation of three large vessels ('triple' cannulation), resulting in veno-veno-arterial or veno-arterio-venous cannulation. While the former intends to improve drainage and unloading, the latter represents a very potent method to provide circulatory and respiratory support at the same time. As such triple cannulation expands the field of application at the expense of increased complexity of ECMO systems. Here, we review percutaneous dual and triple cannulation strategies for different clinical scenarios of the critically ill. As there is no unifying terminology to date, we propose a nomenclature which uses "A" and all following letters for supplying cannulas and all letters before "A" for draining cannulas. This general and unequivocal code covers both dual and triple ECMO cannulation strategies (VV, VA, VVA, VAV). Notwithstanding the technical evolution, current knowledge of ECMO support is mainly based on observational experience and mostly retrospective studies. Prospective controlled trials are urgently needed to generate evidence on safety and efficacy of ECMO support in different clinical settings.

Elective Thoracoscopic Maze with Venoarterial Extracorporeal Life Support

This case report describes the intraoperative use of extracorporeal life support (ECLS) for an elective thoracoscopic maze procedure in which the patient could not tolerate one-lung ventilation because of hypoxia. Potential pitfalls associated with the anesthetic management of elective intraoperative ECLS include managing native cardiac ejection and ECLS flows to provide optimal oxygenation and cardiac output. Particular attention must be paid to cardiac and respiratory physiology when ECLS is used in a patient with normal cardiac function.

Emergency and prophylactic use of miniaturized veno-arterial extracorporeal membrane oxygenation in transcatheter aortic valve implantation

OBJECTIVES

To report our center's experience using veno-arterial extracorporeal membrane oxygenation (vaECMO) in transcatheter aortic valve implantation (TAVI).

BACKGROUND

In TAVI, short-term mortality closely relates to life threatening procedural complications. VaECMO can be used to stabilize the patient in emergency situations. However, for the prophylactic use of vaECMO in very high-risk patients undergoing TAVI there is no experience.

METHODS

From January 2009 to August 2011, we performed 131 TAVI. Emergency vaECMO was required in 8 cases (7%): ventricular perforation (n = 3), hemodynamic instability/cardiogenic shock (n = 4), hemodynamic deterioration due to ventricular tachycardia (n = 1). Since August 2011, during 83 procedures, prophylactic vaECMO was systematically used in very high-risk patients (n = 9, 11%) and emergency ECMO in one case (1%) due to ventricular perforation.

RESULTS

Median logistic EuroScore in prophylactic vaECMO patients was considerably higher as compared to the remaining TAVI population (30% vs. 15%, P = 0.0003) while in patients with emergency vaECMO it was comparable (18% vs. 15%, P = 0.08). Comparing prophylactic to emergency vaECMO, procedural success and 30-day mortality were 100% vs. 44% (P = 0.03) and 0% vs. 44% (P = 0.02), respectively. Major vascular complications and rate of life threatening bleeding did not differ between both groups (11% vs. 11%, P = 0.99 and 11% vs. 33%, P = 0.3) and were not vaECMO-related.

CONCLUSIONS

Life-threatening complications during TAVI can be managed using emergency vaECMO but mortality remains high. The use of prophylactic vaECMO in very high-risk patients is safe and may be advocated in selected cases.