1887
Volume 2017, Issue 1
  • ISSN: 0253-8253
  • E-ISSN: 2227-0426

Abstract

The application of veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is becoming an increasingly frequent procedure in emergency medicine.1 Correct appraisal of clinical conditions and patient selection are critical not only in terms of expected outcome, but also in terms of adequate temporary support configuration, optimization of resources, and organization of daily hospital activities, since inappropriate implant may remarkably impact all these aspects.

According to recent analysis of ECMO use in the USA,1 VA-ECMO was most commonly applied in post-cardiac surgery candidates, however with a constant decline for the period from 2007 to 2011. Indeed, from 57% of the total ECMO cases, post-cardiotomy VA-ECMO went to 38%, but with a significant rise in cases of cardio-pulmonary failure (from 3.9 to 11.1%).1 This situation is certainly further changing during the last 5 years as VA-ECMO in cardiogenic shock and cardiac arrest is becoming more popular. Patient selection in this setting is rather variable. However, potential cardiac etiology (acute myocardial infarction – AMI) represents almost 50% of the causes, and witnessed cardiac arrest, immediate cardio-pulmonary resuscitation (CPR) by bystanders, adequate CPR (possibly with mechanical cardiac massage devices), and not prolonged time from cardiac arrest to ECMO application ( < 60 min) represent positive predictors in the setting of extracorporeal cardio-pulmonary resuscitation (ECPR).2 Recent publications have shown that ECPR might achieve respectful outcome also in elderly patients.3,4,5 Therefore, age should not disqualify potential candidates. Absence of severe acidosis and still acceptable end-tidal CO may represent additional elements for patient selection in this setting. ECMO results in this setting appear rather unsatisfactory with in-hospital survival below 30%.5 Prompt initiation of ECMO and avoiding unnecessary prolonged cardio-pulmonary bypass and metabolic as well as coagulation derangement are among the most relevant key factors. The absence of severe cardiac or co-morbidities prior to surgery and the expected temporary impairment of the cardio-respiratory systems represent additional indications for post-cardiotomy ECMO. This setting represents the most expanding field of ECMO application. Indications may derive from refractoriness of cardio-circulatory impairment to conventional therapies (drug and IABP). Moreover, in this setting, advanced age and severe co-morbidities may represent relative contraindications. Furthermore, in this field, the potential for cardiac recovery or the possibility to bridge the patient to other treatments, if recovery is considered unlikely, represents indication for ECMO use. VA-ECMO is generally indicated if right ventricular dysfunction is present or develops, and if VV-ECMO does not provide sufficient peripheral oxygenation. In the last case, hybrid configuration (VVA or VAV) might be more suitable and advisable. Sepsis, trauma (most often treated with VV-ECMO), fulminant myocarditis, Tako-Tsubo, or complicated interventional procedures (TAVI, PCI, balloon valvuloplasty) represent areas in which ECMO is increasingly applied.6,7 Despite wider use in these settings, more clinical evidences are still needed to conclusively define patient selection criteria and ultimate benefits. Finally, a developing indication might be in critically ill patients undergoing either cardiac surgery or interventional cardiological procedures. In these patients, in whom post-procedural severely complicated course is expected, timely and pre-crash support may help to provide a smooth peri-procedural period. Short-time controlled support of cardio-circulatory system and peripheral organ perfusion, with avoidance of metabolic and hemodynamic derangement, may also affect emergency VA-ECMO implant should patient deterioration occur, and allow a better complicated patient management with better final outcome.

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/content/journals/10.5339/qmj.2017.swacelso.22
2017-02-14
2019-08-24
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References

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