Unloading Is Not the Only Question in Cardiogenic Shock

Preserving flow, saving lives: Successful treatment of aortic valve failure in acute myocardial infarction without flow down-regulation using ECMO - a case report and mini review

Direct percutaneous coronary intervention (PPCI) has significantly reduced cardiac mortality in patients with acute myocardial infarction (AMI), but the mortality rate remains high for those who develop cardiogenic shock (CS), reaching 40% to 50%. Veno-arterial extracorporeal membrane oxygenation (V-A ECMO) provides robust hemodynamic support and oxygen delivery for AMI patients with refractory CS, ensuring adequate organ perfusion and oxygen supply. However, there is currently no standardized optimal Mean Arterial Pressure (MAP) range during V-A ECMO support. Achieving the proper MAP is crucial for adequate myocardial perfusion, cardiac function recovery, successful weaning off of V-A ECMO, and improving long-term outcomes. In this case study, we successfully treated a 55-year-old man with AMI and refractory cardiogenic shock using V-A ECMO. By adjusting ECMO blood flow and employing hemodynamic strategies, including vasoactive drugs, we optimized the MAP, leading to improved cardiac function and successful weaning off of V-A ECMO. This presents a potential opportunity for MAP optimization under ECMO support in patients with acute myocardial infarction and cardiogenic shock.

Left Ventricular Unloading during Extracorporeal Life Support: Current Practice

Veno-arterial extracorporeal life support (VA-ECLS) is a powerful tool that can provide complete cardiopulmonary support for patients with refractory cardiogenic shock. However, VA-ECLS increases left ventricular afterload resulting in greater myocardial oxygen demand, which can impair myocardial recovery and worsen pulmonary edema. These complications can be ameliorated by various LV venting strategies to unload the LV. Evidence suggests that LV venting improves outcomes in VA-ECLS, but there is a paucity of randomized trials to help guide optimal strategy and the timing of venting. In this review, we discuss the available evidence regarding LV venting in VA-ECLS, explain important hemodynamic principles involved, and propose a practical approach to LV venting in VA-ECLS.

Management of Common Cardiovascular Emergencies in Critically Ill Patients

This article reviews treatment and management of common cardiovascular emergencies in critically ill patients, focusing on acute decompensated heart failure, cardiogenic shock, pulmonary embolism, and hypertensive crisis management with inotropes, vasopressors, diuretics, and antiarrhythmic drugs. Clinicians frequently come across challenging clinical scenarios, and there is a gap between evidence-based medicine and clinical practice. Inotropic and vasopressor agents are useful in the acute setting but must be weaned off or used as a bridge for mechanical circulation support devices. Clinicians should aim to lower complications by choosing medications with respect to comorbidities and close the gap between evidence-based medicine and clinical practice.