Percutaneous Unloading of the Left Ventricle during Extracorporeal Membrane Oxygenation in Cardiogenic Shock - Ongoing Experience from a High-volume Centre

Objectives: We recently published data on the beneficial impact of left ventricular (LV) unloading with a percutaneous ventricular assist device (pVAD) during extracorporeal membrane oxygenation (ECMO) for patients in cardiogenic shock (CS) as compared with a matched cohort of patient on ECMO without mechanical unloading. Here, we present ongoing experience with this approach.

Methods: 90 patients with CS were treated with an ECMO plus pVAD (Impella® CP or 2.5, Abiomed Inc.) at our institution from September 2013 until September 2017. Patients were male in 77% with a mean age of 55 (± 12.9) years. The CS was of ischemic origin in 60% of the cases, in 30% an acute decompensated heart failure was present and in 10% the underlying cause was an acute myocarditis. A total of 80% of the patients underwent cardiopulmonary resuscitation (CPR) before implantation of the ECMO and in 45% the ECMO was implanted under active CPR. Mean lactate upon presentation was 9.5 (±5.8) mmol/L with a mean pH of 7.1 (±0.2). SAVE-Score was −12 (±6.0) predicting a survival rate below 20%. The ECMO and the pVAD were implanted via femoral access with distal perfusion cannula at both sides whenever possible.

Results: Mean time on ECMO and pVAD were 7 (±6) days. 52% of the patients were successfully weaned from the ECMO with the help of the pVAD. In 5% of the cases patients were not weaned from the ECMO but directly implanted with a durable left ventricular assist device (LVAD). In another 5% patients underwent transition from ECMO to a high-flow pVAD (Impella® 5.0, Abiomed Inc.) and received an LVAD later on. 30-day survival rate was 45%, which is significantly higher as the predicted survival rate by the SAVE-Score. Relevant bleeding complications were seen in 18% of the cases and in 25% of the cases we observed peripheral vascular complications.

Conclusion: LV unloading using a pVAD is a promising option for patient with CS on ECMO. In parallel to our previously published data, the ongoing experience with this approach confirms an improved survival rate in these patients compared with patients treated with ECMO alone. Furthermore, this approach facilitates the weaning procedure as it allows the treating physician to access multiple weaning options. Although two devices were used, the bleeding and ischemic complications were not increased as compared with published data on ECMO alone.