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Carnicelli AP, Diepen SV, Gage A, Berhnardt AM, Houston BA, Siuba MT, Kataria R, Beavers CJ, John KJ, Meyns B, Kapur N, Tedford RJ, Kanwar M. Pragmatic Approach to Temporary Mechanical Circulatory Support in Acute Right Ventricular Failure. J Heart Lung Transplant 2024:S1053-2498(24)01740-6. [PMID: 39059594 DOI: 10.1016/j.healun.2024.07.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2024] [Revised: 07/02/2024] [Accepted: 07/08/2024] [Indexed: 07/28/2024] Open
Abstract
Acute right ventricular failure (RVF) is prevalent in multiple disease states and is associated with poor clinical outcomes. Right-sided temporary mechanical circulatory support (tMCS) devices are used to unload RV congestion and increase cardiac output in cardiogenic shock (CS) with hemodynamically significant RVF. Several RV-tMCS device platforms are available; however consensus is lacking on patient selection, timing of escalation to RV-tMCS, device management, and device weaning. The purposes of this review are to 1) describe the current state of tMCS device therapies for acute RVF with CS, 2) discuss principles of escalation to RV-tMCS device therapy, 3) examine important aspects of clinical management for patients supported by RV-tMCS devices including volume management, anticoagulation, and positive pressure ventilation, and 4) provide a framework for RV-tMCS weaning.
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Affiliation(s)
- Anthony P Carnicelli
- Division of Cardiology, Department of Medicine, Medical University of South Carolina, Charleston, SC, USA.
| | - Sean van Diepen
- Department of Critical Care Medicine and Division of Cardiology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Ann Gage
- Department of Cardiology, Centennial Medical Center, Nashville, TN, USA
| | - Alexander M Berhnardt
- Department of Cardiovascular Surgery, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Brian A Houston
- Division of Cardiology, Department of Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Matt T Siuba
- Department of Critical Care Medicine, Integrated Hospital Care Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Rachna Kataria
- Division of Cardiology, Department of Medicine, Lifespan Cardiovascular Institute, Rhode Island Hospital, Providence, RI, USA
| | - Craig J Beavers
- University of Kentucky College of Pharmacy, Lexington, KY, USA
| | - Kevin J John
- Division of Cardiology, Department of Medicine, Tufts Medical Center, Boston, MA, USA
| | - Bart Meyns
- Department of Cardiothoracic Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Navin Kapur
- Division of Cardiology, Department of Medicine, Tufts Medical Center, Boston, MA, USA
| | - Ryan J Tedford
- Division of Cardiology, Department of Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Manreet Kanwar
- Cardiovascular Institute at Allegheny Health Network, Pittsburgh, PA, USA
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2
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Matsumura K, Shimizu K, Horikoshi Y, Hamaguchi J, Matsuyoshi T, Sasaki J. Novel weaning assessment for veno-arteriovenous to veno-venous extracorporeal membrane oxygenation using pump-controlled retrograde trial off. Perfusion 2024:2676591241258689. [PMID: 38808770 DOI: 10.1177/02676591241258689] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/30/2024]
Abstract
INTRODUCTION Pump-controlled retrograde trial off (PCRTO) is described as an effective weaning strategy for veno-arterial extracorporeal membrane oxygenation (ECMO) in the guidelines. Contrastingly, there is no established weaning strategy for veno-arteriovenous (V-AV) ECMO. We report a novel application of PCRTO in a patient undergoing V-AV ECMO. CASE REPORT A 49-year-old man had pneumonia and a history of kidney transplantation. Two days after intubation, respiratory failure progressed and veno-venous (V-V) ECMO was introduced. On day 7 after ECMO, the configuration was changed to V-AV ECMO owing to septic cardiomyopathy due to suspected cholangitis. On day 15, with partial haemodynamic improvement and persistent respiratory failure, PCRTO was performed; the patient was safely returned to V-V ECMO. DISCUSSION In patients undergoing V-AV ECMO, PCRTO could have the potential to accurately simulate decannulation of the arterial cannula. CONCLUSION This novel weaning strategy could be considered in patients undergoing V-AV ECMO.
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Affiliation(s)
- Kazuki Matsumura
- ECMO Center, Department of Emergency and Critical Care Medicine, Tokyo Metropolitan Tama Medical Center, Fuchu, Japan
- Department of Emergency and Critical Care Medicine, Keio University School of Medicine, Shinjuku, Japan
| | - Keiki Shimizu
- ECMO Center, Department of Emergency and Critical Care Medicine, Tokyo Metropolitan Tama Medical Center, Fuchu, Japan
| | - Yuichi Horikoshi
- ECMO Center, Department of Emergency and Critical Care Medicine, Tokyo Metropolitan Tama Medical Center, Fuchu, Japan
| | - Jun Hamaguchi
- ECMO Center, Department of Emergency and Critical Care Medicine, Tokyo Metropolitan Tama Medical Center, Fuchu, Japan
| | - Takeo Matsuyoshi
- ECMO Center, Department of Emergency and Critical Care Medicine, Tokyo Metropolitan Tama Medical Center, Fuchu, Japan
| | - Junichi Sasaki
- Department of Emergency and Critical Care Medicine, Keio University School of Medicine, Shinjuku, Japan
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Zhao Y, Wang H, Cheng Y, Zhang J, Zhao L. Factors Influencing Successful Weaning From Venoarterial Extracorporeal Membrane Oxygenation: A Systematic Review. J Cardiothorac Vasc Anesth 2024:S1053-0770(24)00328-8. [PMID: 38969612 DOI: 10.1053/j.jvca.2024.05.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2023] [Revised: 05/01/2024] [Accepted: 05/11/2024] [Indexed: 07/07/2024]
Abstract
With advancements in extracorporeal life support (ECLS) technologies, venoarterial extracorporeal membrane oxygenation (VA-ECMO) has emerged as a crucial cardiopulmonary support mechanism. This review explores the significance of VA-ECMO system configuration, cannulation strategies, and timing of initiation. Through an analysis of medication management strategies, complication management, and comprehensive preweaning assessments, it aims to establish a multidimensional evaluation framework to assist clinicians in making informed decisions regarding weaning from VA-ECMO, thereby ensuring the safe and effective transition of patients.
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Affiliation(s)
- Yanlong Zhao
- Department of Cardiology, The Second Hospital of Jilin University, Changchun, Jilin, China
| | - Heru Wang
- Department of Cardiology, The Second Hospital of Jilin University, Changchun, Jilin, China
| | - Yihao Cheng
- Department of Cardiology, The First Hospital of Jilin University, Changchun, Jilin, China
| | - Jifeng Zhang
- School of Pharmaceutical Sciences, Jilin University, Changchun, Jilin, China
| | - Lei Zhao
- Department of Cardiology, The Second Hospital of Jilin University, Changchun, Jilin, China.
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Douflé G, Dragoi L, Morales Castro D, Sato K, Donker DW, Aissaoui N, Fan E, Schaubroeck H, Price S, Fraser JF, Combes A. Head-to-toe bedside ultrasound for adult patients on extracorporeal membrane oxygenation. Intensive Care Med 2024; 50:632-645. [PMID: 38598123 DOI: 10.1007/s00134-024-07333-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Accepted: 01/20/2024] [Indexed: 04/11/2024]
Abstract
Bedside ultrasound represents a well-suited diagnostic and monitoring tool for patients on extracorporeal membrane oxygenation (ECMO) who may be too unstable for transport to other hospital areas for diagnostic tests. The role of ultrasound, however, starts even before ECMO initiation. Every patient considered for ECMO should have a thorough ultrasonographic assessment of cardiac and valvular function, as well as vascular anatomy without delaying ECMO cannulation. The role of pre-ECMO ultrasound is to confirm the indication for ECMO, identify clinical situations for which ECMO is not indicated, rule out contraindications, and inform the choice of ECMO configuration. During ECMO cannulation, the use of vascular and cardiac ultrasound reduces the risk of complications and ensures adequate cannula positioning. Ultrasound remains key for monitoring during ECMO support and troubleshooting ECMO complications. For instance, ultrasound is helpful in the assessment of drainage insufficiency, hemodynamic instability, biventricular function, persistent hypoxemia, and recirculation on venovenous (VV) ECMO. Lung ultrasound can be used to monitor signs of recovery on VV ECMO. Brain ultrasound provides valuable diagnostic and prognostic information on ECMO. Echocardiography is essential in the assessment of readiness for liberation from venoarterial (VA) ECMO. Lastly, post decannulation ultrasound mainly aims at identifying post decannulation thrombosis and vascular complications. This review will cover the role of head-to-toe ultrasound for the management of adult ECMO patients from decision to initiate ECMO to the post decannulation phase.
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Affiliation(s)
- Ghislaine Douflé
- Interdepartmental Division of Critical Care Medicine of the University of Toronto, Toronto, ON, Canada.
- Department of Anesthesia and Pain Management, Toronto General Hospital, 585 University Avenue, Toronto, ON, M5G 2N2, Canada.
| | - Laura Dragoi
- Interdepartmental Division of Critical Care Medicine of the University of Toronto, Toronto, ON, Canada
| | - Diana Morales Castro
- Interdepartmental Division of Critical Care Medicine of the University of Toronto, Toronto, ON, Canada
| | - Kei Sato
- Critical Care Research Group, The Prince Charles Hospital, Level 3 Clinical Sciences Building, Chermside, QLD, 4032, Australia
- Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
| | - Dirk W Donker
- Intensive Care Center, University Medical Center Utrecht (UMCU), Utrecht, The Netherlands
- Cardiovascular and Respiratory Physiology, TechMed Centre, University of Twente, Enschede, The Netherlands
| | - Nadia Aissaoui
- Service de Médecine intensive-réanimation, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris (AP-HP), Université Paris Cité, Paris, France
| | - Eddy Fan
- Interdepartmental Division of Critical Care Medicine of the University of Toronto, Toronto, ON, Canada
| | - Hannah Schaubroeck
- Department of Intensive Care Medicine, Department of Internal Medicine and Pediatrics, Ghent University Hospital, Ghent University, Corneel Heymanslaan 10, 9000, Ghent, Belgium
| | - Susanna Price
- Departments of Cardiology and Intensive Care, Royal Brompton & Harefield NHS Foundation Trust, London, UK
- National Heart and Lung Institute, Imperial College London, London, UK
| | - John F Fraser
- Critical Care Research Group, The Prince Charles Hospital, Level 3 Clinical Sciences Building, Chermside, QLD, 4032, Australia
- Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
| | - Alain Combes
- Service de Médecine Intensive-Réanimation, Institut de Cardiologie, APHP Sorbonne Université, Hôpital Pitié Salpêtrière, Paris, France
- Institute of Cardiometabolism and Nutrition, Sorbonne Université, INSERM, UMRS_1166-ICAN, Paris, France
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Lim HS. A novel 'shunt fraction' method to derive native cardiac output during liberation from central VA ECMO. ESC Heart Fail 2024; 11:570-573. [PMID: 37915262 PMCID: PMC10804194 DOI: 10.1002/ehf2.14441] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Revised: 05/26/2023] [Accepted: 06/08/2023] [Indexed: 11/03/2023] Open
Abstract
The Fick principle is an established method to quantify intracardiac shunts. The Fick principle has also found utility in the practice of extracorporeal membrane oxygenation (ECMO). This report describes a novel 'shunt fraction' method to calculate intrinsic cardiac output in central (right atrial-to-aorta) ECMO. The physiological basis of this 'shunt fraction' method is described, followed by the case presentation that details the clinical application of this method of quantifying intrinsic cardiac output to guide weaning and liberation from central VA ECMO.
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Affiliation(s)
- Hoong Sern Lim
- University Hospitals Birmingham NHS Foundation TrustBirminghamUK
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Corujo Rodriguez A, Richter E, Ibekwe SO, Shah T, Faloye AO. Postcardiotomy Shock Syndrome: A Narrative Review of Perioperative Diagnosis and Management. J Cardiothorac Vasc Anesth 2023; 37:2621-2633. [PMID: 37806929 DOI: 10.1053/j.jvca.2023.09.011] [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] [Received: 06/14/2023] [Revised: 08/29/2023] [Accepted: 09/09/2023] [Indexed: 10/10/2023]
Abstract
Postcardiotomy shock (PCS) is generally described as the inability to separate from cardiopulmonary bypass due to ineffective cardiac output after cardiotomy, which is caused by a primary cardiac disorder, resulting in inadequate tissue perfusion. Postcardiotomy shock occurs in 0.5% to 1.5% of contemporary cardiac surgery cases, and is accompanied by an in-hospital mortality of approximately 67%. In the last 2 decades, the incidence of PCS has increased, likely due to the increased age and baseline morbidity of patients requiring cardiac surgery. In this narrative review, the authors discuss the epidemiology and pathophysiology of PCS, the rationale and evidence behind the initiation, continuation, escalation, and discontinuation of mechanical support devices in PCS, and the anesthetic implications.
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Affiliation(s)
| | - Ellen Richter
- Department of Anesthesiology, Emory University, Atlanta, GA
| | | | - Tina Shah
- Department of Anesthesiology, Emory University, Atlanta, GA
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Díaz-Gómez JL, Hendon AA. Advanced Perioperative Echocardiography in Venoarterial Extracorporeal Membrane Oxygenation Weaning Trial-Off. Tex Heart Inst J 2023; 50:e238171. [PMID: 37485838 PMCID: PMC10655858 DOI: 10.14503/thij-23-8171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/25/2023]
Affiliation(s)
- José L. Díaz-Gómez
- Department of Anesthesiology, Baylor College of Medicine, Houston, Texas
- Department of Anesthesiology and Critical Care Medicine, The Texas Heart Institute, Houston, Texas
| | - Alec A. Hendon
- Department of Anesthesiology, Baylor College of Medicine, Houston, Texas
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Brahmbhatt DH, Rao V. Commentary: Bridge to bridge: No longer a bridge too far for successful cardiac transplant. J Thorac Cardiovasc Surg 2023; 165:1149-1150. [PMID: 34642078 DOI: 10.1016/j.jtcvs.2021.09.041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Revised: 09/23/2021] [Accepted: 09/24/2021] [Indexed: 11/25/2022]
Affiliation(s)
- Darshan H Brahmbhatt
- Ted Rogers Centre for Heart Function Research, Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada; Division of Cardiology, University of Toronto, Toronto, Ontario, Canada; National Heart & Lung Institute, Imperial College London, London, United Kingdom
| | - Vivek Rao
- Ted Rogers Centre for Heart Function Research, Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada; Division of Cardiovascular Surgery, University of Toronto, Toronto, Ontario, Canada.
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9
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Castro DM, Morris I, Teijeiro-Paradis R, Fan E. Monitoring during extracorporeal membrane oxygenation. Curr Opin Crit Care 2022; 28:348-359. [PMID: 35275878 DOI: 10.1097/mcc.0000000000000939] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Extracorporeal membrane oxygenation (ECMO) offers advanced mechanical support to patients with severe acute respiratory and/or cardiac failure. Ensuring an adequate therapeutic approach as well as prevention of ECMO-associated complications, by means of timely liberation, forms an essential part of standard ECMO care and is only achievable through continuous monitoring and evaluation. This review focus on the cardiorespiratory monitoring tools that can be used to assess and titrate adequacy of ECMO therapy; as well as methods to assess readiness to wean and/or discontinue ECMO support. RECENT FINDINGS Surrogates of tissue perfusion and near infrared spectroscopy are not standards of care but may provide useful information in select patients. Echocardiography allows to determine cannulas position, evaluate cardiac structures, and function, and diagnose complications. Respiratory monitoring is mandatory to achieve lung protective ventilation and identify early lung recovery, surrogate measurements of respiratory effort and ECMO derived parameters are invaluable in optimally managing ECMO patients. SUMMARY Novel applications of existing monitoring modalities alongside evolving technological advances enable the advanced monitoring required for safe delivery of ECMO. Liberation trials are necessary to minimize time sensitive ECMO related complications; however, these have yet to be standardized.
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Affiliation(s)
- Diana Morales Castro
- Interdepartmental Division of Critical Care Medicine, Toronto General Hospital
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Canada
| | - Idunn Morris
- Interdepartmental Division of Critical Care Medicine, Toronto General Hospital
- Discipline of Intensive Care Medicine, Nepean Clinical School, Faculty of Medicine and Health, The University of Sydney, NSW, Australia
| | | | - Eddy Fan
- Interdepartmental Division of Critical Care Medicine, Toronto General Hospital
- Institute of Health Policy, Management and Evaluation
- Department of Medicine, University of Toronto, Toronto, Canada
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10
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Affiliation(s)
- Hoong Sern Lim
- University Hospital Birmingham NHS Foundation Trust, Edgbaston, Birmingham, United Kingdom
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11
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Araj FG, Hackmann AE. Letter by Araj and Hackmann Regarding Article, "Liberation From Venoarterial Extracorporeal Membrane Oxygenation: A Review". Circ Heart Fail 2022; 15:e009079. [PMID: 35026954 DOI: 10.1161/circheartfailure.121.009079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Faris G Araj
- Department of Internal Medicine, Division of Cardiology (F.G.A.), University of Texas Southwestern Medical Center, Dallas
| | - Amy E Hackmann
- Department of Cardiovascular and Thoracic Surgery (A.E.H.), University of Texas Southwestern Medical Center, Dallas
- Chief of ECMO and Temporary Mechanical Support, University of Texas Southwestern Medical Center and Parkland Health and Hospital System, Dallas (A.E.H.)
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12
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Brahmbhatt DH, Daly AL, Luk AC, Fan E, Billia F. Response by Brahmbhatt et al to Letter Regarding Article, "Liberation From Venoarterial Extracorporeal Membrane Oxygenation: A Review". Circ Heart Fail 2022; 15:e009260. [PMID: 35026962 DOI: 10.1161/circheartfailure.121.009260] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Darshan H Brahmbhatt
- Division of Cardiology, Peter Munk Cardiac Centre, University Health Network, Toronto, ON, Canada (D.H.B., A.L.D., A.C.L., F.B.)
- Department of Medicine (D.H.B., A.C.L., F.B.), University of Toronto, ON, Canada
- National Heart & Lung Institute, Imperial College London, United Kingdom (D.H.B.)
- Ted Rogers Centre for Heart Research, Toronto, ON, Canada (D.H.B., A.C.L., F.B.)
| | - Andrea L Daly
- Division of Cardiology, Peter Munk Cardiac Centre, University Health Network, Toronto, ON, Canada (D.H.B., A.L.D., A.C.L., F.B.)
| | - Adriana C Luk
- Division of Cardiology, Peter Munk Cardiac Centre, University Health Network, Toronto, ON, Canada (D.H.B., A.L.D., A.C.L., F.B.)
- Department of Medicine (D.H.B., A.C.L., F.B.), University of Toronto, ON, Canada
- Ted Rogers Centre for Heart Research, Toronto, ON, Canada (D.H.B., A.C.L., F.B.)
| | - Eddy Fan
- Interdepartmental Division of Critical Care Medicine (E.F.), University of Toronto, ON, Canada
- Toronto General Hospital Research Institute, University Health Network, ON, Canada (E.F., F.B.)
| | - Filio Billia
- Division of Cardiology, Peter Munk Cardiac Centre, University Health Network, Toronto, ON, Canada (D.H.B., A.L.D., A.C.L., F.B.)
- Department of Medicine (D.H.B., A.C.L., F.B.), University of Toronto, ON, Canada
- Ted Rogers Centre for Heart Research, Toronto, ON, Canada (D.H.B., A.C.L., F.B.)
- Toronto General Hospital Research Institute, University Health Network, ON, Canada (E.F., F.B.)
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13
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Extracorporeal Membrane Oxygenation in Infarct-Related Cardiogenic Shock. J Clin Med 2022; 11:jcm11051256. [PMID: 35268347 PMCID: PMC8910965 DOI: 10.3390/jcm11051256] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Revised: 02/21/2022] [Accepted: 02/22/2022] [Indexed: 12/18/2022] Open
Abstract
Mortality in infarct-related cardiogenic shock (CS) remains high, reaching 40–50%. In refractory CS, active mechanical circulatory support devices including veno-arterial extracorporeal membrane oxygenation (VA-ECMO) are rapidly evolving. However, supporting evidence of VA-ECMO therapy in infarct-related CS is low. The current review aims to give an overview on the basics of VA-ECMO therapy, current evidence, ongoing trials, patient selection and potential complications.
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