Left Ventricular Unloading in Extracorporeal Membrane Oxygenation: A Clinical Perspective Derived from Basic Cardiovascular Physiology

• Published in: Current cardiology reports Vol. 26; no. 7; pp. 661 - 667
• Main Authors: Protti, I., van Steenwijk, M. P. J., Meani, P., Fresiello, L., Meuwese, C. L., Donker, D. W.
• Format: Journal Article
• Language: English
• Published: New York Springer US 01.07.2024
• Subjects: Cardiology; Cardiovascular Critical Care (A Higgins and R Lee; Cardiovascular Critical Care (A Higgins and R Lee, Section Editors); Extracorporeal Membrane Oxygenation - methods; Heart Ventricles - physiopathology; Heart-Assist Devices; Humans; Medicine; Medicine & Public Health; Myocardial Infarction - physiopathology; Myocardial Infarction - therapy; Section Editors; Shock, Cardiogenic - physiopathology; Shock, Cardiogenic - therapy; Topical Collection on Cardiovascular Critical Care; Ventricular Function, Left - physiology; Temporary mechanical circulatory support (TCS); Computational physiological modeling; Mechanical circulatory support (MCS); Extracorporeal life support (ECLS); Impella; Intra-aortic balloon pump (IABP); Left ventricular unloading; Veno-arterial extracorporeal membrane oxygenation (V-A ECMO)
• ISSN: 1523-3782; 1534-3170; 1534-3170
• DOI: 10.1007/s11886-024-02067-w

Purpose of Review To present an abridged overview of the literature and pathophysiological background of adjunct interventional left ventricular unloading strategies during veno-arterial extracorporeal membrane oxygenation (V-A ECMO). From a clinical perspective, the mechanistic complexity of such combined mechanical circulatory support often requires in-depth physiological reasoning at the bedside, which remains a cornerstone of daily practice for optimal patient-specific V-A ECMO care. Recent Findings Recent conventional clinical trials have not convincingly shown the superiority of V-A ECMO in acute myocardial infarction complicated by cardiogenic shock as compared with medical therapy alone. Though, it has repeatedly been reported that the addition of interventional left ventricular unloading to V-A ECMO may improve clinical outcome. Novel approaches such as registry-based adaptive platform trials and computational physiological modeling are now introduced to inform clinicians by aiming to better account for patient-specific variation and complexity inherent to V-A ECMO and have raised a widespread interest. Summary To provide modern high-quality V-A ECMO care, it remains essential to understand the patient's pathophysiology and the intricate interaction of an individual patient with extracorporeal circulatory support devices. Innovative clinical trial design and computational modeling approaches carry great potential towards advanced clinical decision support in ECMO and related critical care.