Left ventricular unloading during reperfusion.

Ambulatory simultaneous venoarterial extracorporeal membrane oxygenation and temporary percutaneous left ventricular assist device bridge to heart transplantation

Cannula and Pump Positions Are Associated With Left Ventricular Unloading and Clinical Outcome in Patients With HeartWare Left Ventricular Assist Device

Left ventricular (LV) unloading is a crucial intervention to decrease the harmful consequences of extracorporeal membrane oxygenation (ECMO) on hemodynamic status in cardiogenic shock (CS) patients. However, a lingering question preoccupies experts: Should we intervene early or wait until clinical deterioration caused by increasing afterload is detected? A systematic review and meta-analysis synthesizing studies, which were retrieved by systematically searching PubMed, Web of Science, SCOPUS, and Cochrane through December 2023. We used R V. 4.3 to pool dichotomous data using risk ratio (RR) and continuous data using mean difference (MD) with a 95% confidence interval (CI). CRD42024501643. Eight studies with 2.117 patients were included. Early/prophylactic LV unloading was associated with a lower incidence of all-cause mortality [RR: 0.87 with 95% CI (0.79, 0.95), p < 0.01]. However, there was no significant difference between the two groups regarding cardiac mortality [RR: 1.01 with 95% CI (0.68, 1.48), p = 0.98], non-cardiac mortality [RR: 0.86 with 95% CI (0.46, 1.62), p = 0.64], and in-hospital mortality [RR: 0.95 with 95% CI (0.86, 1.05), p = 0.30]. There was no significant difference between the two groups regarding ECMO weaning, myocardial recovery, ECMO duration, and length of hospitalization. Early/prophylactic LV unloading during ECMO for CS patients was associated with a decreased incidence of all-cause mortality and sepsis or infection, with no effect on ECMO weaning, myocardial recovery, ECMO duration, and hospital length of stay.

Aims: Unclear neurological outcome often precludes severely compromised patients after out-of-hospital cardiac arrest (OHCA) from mechanical circulatory support (MCS), while it may be considered as rescue therapy for patients with refractory cardiogenic shock (rCS) in the absence of OHCA. This analysis sought to investigate the role of left ventricular (LV) unloading in patients with rCS related to acute myocardial infarction (AMI) after OHCA.Methods: Of 273 consecutive patients receiving microaxial pumps in the Hannover Cardiac Unloading Registry between January 2013 and August 2018, 47 presented with AMI–rCS following successful resuscitation. Subsequently, the patients were compared by propensity score matching to patients with OHCA AMI–rCS without MCS. The patient data for OHCA without LV unloading was available from 280 patients of the Hannover Cooling Registry for the same time period. Furthermore, the patients with OHCA without rCS were compared to the patients with OHCA AMI–rCS and LV unloading.Results: In total, 15 OHCA AMI–rCS patients without MCS were matched to patients with AMI–rCS and Impella. Patients without LV support had a higher proportion of a cardiac cause of death (n = 7 vs. n = 3; p = 0.024). LV unloading with Impella counteract rCS status and was associated with a preferable 30-day survival (66.7 vs. 20%, p = 0.01) and a favorable neurological outcome after 30 days (Cerebral Performance Category ≤2, 47 vs. 27%). Impella support is associated with a higher 30-day survival (odds ratio, 2.67; 95% confidence interval, 1.02–13.66).Conclusion: In patients after OHCA with AMI–rCS, Impella support incorporated in a strict standardized treatment algorithm results in a preferable 30-day survival and counteracts severe rCS status.

Left Ventricular Unloading During Extracorporeal Membrane Oxygenation: Insights From Meta-Analyzed Observational Data Corrected for Confounders

Pulmonary artery (PA) cannulation during peripheral venoarterial extracorporeal membrane oxygenation (ECMO) has been shown to be effective either for indirect left ventricular (LV) unloading or to allow right ventricular (RV) bypass with associated gas-exchange support in case of acute RV with respiratory failure. This case series reports the results of such peculiar ECMO configurations with PA cannulation in different clinical conditions. All consecutive patients receiving PA cannulation (direct or percutaneous) from January 2015 to September 2018 in 3 institutions were retrospectively reviewed. Isolated LV unloading or RV support, as well as dynamic support including initial drainage followed by perfusion through the PA cannula, was used as part of the ECMO configuration according to the type of patient and the patient's haemodynamic/functional needs. Fifteen patients (8 men, age range 45-73 years, EuroSCORE log range 14.45-91.60%) affected by acute LV, RV or biventricular failure of various aetiologies, were supported by this ECMO mode. Percutaneous PA cannulation was performed in 10 patients and direct PA cannulation, in 5 cases. Dynamic ECMO management (initially draining and then perfusing through the PA cannula) was carried out in 6 patients. Mean ECMO duration was 9.1 days (range 6-17 days). One patient exhibited pericardial fluid during the implant of a PA cannula (no lesion found when the chest was opened), and weaning from temporary circulatory support was achieved in 14 patients (1 who received a transplant). Three patients (20%) died in-hospital, and 12 patients were successfully discharged without major complications. Effective indirect LV unloading in peripheral venoarterial ECMO as well as isolated RV support can be achieved by PA cannulation. Such an ECMO configuration may allow the counteraction of common venoarterial ECMO shortcomings or allow dynamic/adjustable management of ECMO according to specific ventricular dysfunction and haemodynamic needs. Percutaneous PA cannulation was shown to be safe and feasible without major complications. Additional investigation is needed to confirm the safety and efficacy of such an ECMO configuration and management in a larger patient population.

Left ventricular (LV) unloading has been shown to improve survival for patients requiring veno-arterial extracorporeal membrane oxygenation (VA ECMO) support for cardiogenic shock. A mortality benefit has been shown for ECMO and concomitant placement of a transcatheter unloading LV pump such as an Impella device (colloquially referred to as ECPELLA or ECMELLA) for patients resuscitated with VA ECMO after a short period of cardiac arrest. Despite the described benefit of LV unloading with VA ECMO for cardiopulmonary resuscitation, it remains unclear as to what criteria should be used and what other diagnostic and therapeutic adjuncts may be useful. We describe here the successful utilization of concomitant VA ECMO and Impella in a 43 year old male with acute heart failure and cardiac arrest. Distinguishing itself from the currently reported methods, our methodology incorporates transesophageal echocardiography (TEE) in the emergency department for rapid decision-making in addition to an automatic chest compression device, the Lund University Cardiac Assist System (LUCAS) device (Stryker, Portage, MI) as a bridge to LV unloading in a hybrid operating suite.

Veno-arterial extracorporeal membrane oxygenation (VA ECMO) is widely used in cardiogenic shock. It provides systemic perfusion, but left ventricular (LV) unloading is suboptimal. Using a closed-loop, real-time computer model of the human cardiovascular system, cardiogenic shock supported by peripheral VA ECMO was simulated, and effects of various adjunct LV unloading interventions were quantified. After VA ECMO initiation (4 L/min) in cardiogenic shock (baseline), hemodynamics improved (increased to 85 mm Hg), while LV overload occurred (10% increase in end-diastolic volume [EDV], and 5 mm Hg increase in pulmonary capillary wedge pressure [PCWP]). Decreasing afterload (65 mm Hg mean arterial pressure) and circulating volume (-800 mL) reduced LV overload (12% decrease in EDV and 37% decrease in PCWP) compared with baseline. Additional intra-aortic balloon pumping only marginally decreased cardiac loading. Instead, adjunct Impella™ enhanced LV unloading (23% decrease in EDV and 41% decrease in PCWP). Alternative interventions, for example, left atrial/ventricular venting, yielded substantial unloading. We conclude that real-time simulations may provide quantitative clinical measures of LV overload, depending on the degree of VA ECMO support and adjunct management. Simulations offer insights into individualized LV unloading interventions in cardiogenic shock supported by VA ECMO as a proof of concept for potential future applications in clinical decision support, which may help to improve individualized patient management in complex cardiovascular disease.

Myocardial Sympathetic Innervation and Long-Term Left Ventricular Mechanical Unloading

Left ventricular unloading before reperfusion reduces endothelin-1 release and calcium overload in porcine myocardial infarction

Chronic septal infarction confers right ventricular protection during mechanical left ventricular unloading

We studied online left ventricular (LV) dynamic effects of mechanical LV unloading directly after percutaneous coronary intervention (PCI). Limited clinical information is available on the direct LV dynamic consequences of LV unloading in patients undergoing high-risk PCI and primary PCI for acute ST-elevation myocardial infarction. The effects of the Impella LP2.5 device on LV dynamics were studied in 11 patients (elective high-risk PCI, n = 6; primary PCI, n = 5). LV pressure and volume were continuously assessed by a pressure-conductance catheter at 4 different support levels of the Impella, from 0 L/min at baseline to 2.5 L/min at maximal support. The response to increased LV unloading was not different between both groups of patients. The pooled data showed no change on global and systolic LV function during increased LV unloading, while diastolic function showed improvement as indicated by an increased LV compliance in all patients. There was a decrease in end-diastolic pressure from 22 +/- 12 to 13 +/- 9 mm Hg (P = 0.0001), in end-diastolic elastance from 0.134 +/- 0.060 to 0.091 +/- 0.064 mm Hg/mL (P = 0.009), and in end-diastolic wall stress from 84 +/- 50 to 47 +/- 39 mm Hg (P = 0.004). LV unloading decreases end-diastolic wall stress and improves diastolic compliance dose-dependently. Our results indicate beneficial LV unloading effects of Impella during high-risk and primary PCI.

Right heart function during prosthetic left ventricular assistance in a porcine model of congestive heart failure

Fulminant myocarditis is a life-threatening event that can present as cardiogenic shock. Human metapneumovirus (hMPV)-associated myocarditis is exceptionally uncommon, particularly in the pediatric population. Treatment may require mechanical ventilation, inotropic agents, vasopressors, and advanced life support systems. In this article, we report an 18-month-old previously healthy infant who presented with severe metabolic acidosis, elevated lactate, and profound biventricular systolic dysfunction secondary to hMPV infection. Despite mechanical ventilation, inotropic support, and initial immunomodulatory therapy with intravenous immunoglobulin, high-dose methylprednisolone, and anakinra, the patient's clinical condition deteriorated rapidly, requiring venoarterial extracorporeal membrane oxygenation (VA-ECMO) within the first 12 hours of admission. Given the absence of a patent foramen ovale and significant ventricular distention risk, surgical left ventricular decompression via a cannula inserted through the right upper pulmonary vein was performed. Hemoadsorption was additionally incorporated to mitigate hyperinflammation. Laboratory findings fulfilled macrophage activation syndrome criteria, and interferon-gamma blockade with emapalumab was initiated due to refractory cytokine storm physiology. Antioxidant therapy (nicotinamide adenine dinucleotide, coenzyme Q10, quercetin) was used as supportive treatment. Progressive improvement in ventricular function was observed under this comprehensive life support-based regimen. By day 12 of ECMO support, biventricular systolic function had normalized, and the patient was successfully weaned and discharged with full recovery. This case underscores the importance of early recognition, advanced immunomodulation, and effective ventricular unloading in managing fulminant hMPV myocarditis in children.

BackgroundLeft ventricular free wall rupture (LVFWR) is a severe complication of acute myocardial infarction that frequently leads to cardiac tamponade and circulatory collapse. Prompt surgical repair and mechanical circulatory support are essential for patient survival. The Impella device provides left ventricular unloading and is increasingly used after cardiac surgeries. However, it carries the risks of bleeding and thromboembolism. Heparin-induced thrombocytopenia (HIT) may be an important contributor to thromboembolic risk. Diagnosing HIT in an acute postoperative setting using the Impella support is particularly challenging. Herein, we present a case of thromboembolism associated with HIT following Impella support after surgical repair of an LVFWR.Case DescriptionA 72-year-old man presented with chest pain. During preparation for percutaneous coronary intervention, the patient developed cardiac arrest and was resuscitated using extracorporeal membrane oxygenation (ECMO) and intra-aortic balloon pumping (IABP). Coronary angiography revealed left circumflex artery occlusion, and echocardiography revealed pericardial effusion. Surgical repair was performed using cardiopulmonary bypass. Intraoperative findings revealed left ventricular rupture in the circumflex artery area. Due to severe ventricular dysfunction, ECMO was continued, and IABP was initially chosen. On postoperative day (POD) 1, after stabilization of bleeding, the IABP was upgraded to Impella for ventricular unloading. ECMO was discontinued on POD 3, and Impella was maintained until POD 9. After Impella was removed, angiography revealed occlusion of both iliac arteries. Bilateral surgical thrombectomy was performed. A latex immunoturbidimetric assay confirmed HIT antibody positivity. Anticoagulation therapy was subsequently switched from heparin to argatroban.ConclusionsThis case illustrates the difficulty in diagnosing HIT in patients on Impella support in the acute postoperative period after cardiac surgery. Clinicians should be vigilant for Impella-associated thromboembolism and understand its possible mechanisms to ensure appropriate diagnosis and prevention.