Comparison of Left Ventricular Unloading Strategies During Extracorporeal Membrane Oxygenation

Venoarterial extracorporeal membrane oxygenation (VA-ECMO) offers cardiopulmonary support with the tradeoff of increased left ventricular (LV) afterload and its adverse sequelae. LV decompression strategies include the use of intra-aortic balloon pump (IABP), indirect LV venting (pulmonary artery cannula [PAC] venting), left atrial venting, and direct LV venting with microaxial flow pump (mAFP). This is a single-institution retrospective study investigating the effect of LV unloading in patients undergoing peripheral VA-ECMO for cardiogenic shock over the study period, January 2017 to November 2022. A total of 184 patients received VA-ECMO support. LV venting/decompression was used in 78 patients (patient underwent an LV venting/decompression strategy [LV+]: 17 IABP, 51 mAFP, 5 PAC vent). Among the LV+ patients, 36 patients received venting before initiation or within 24 hours after initiation of VA-ECMO (early, eLV+), whereas 35 patients were vented greater than 24 hours after VA-ECMO initiation (delayed, dLV+). Post-ECMO diastolic pulmonary artery pressure was similar between vented and unvented groups (p = 0.367) despite worse baseline cardiac function in the vented group (ejection fraction [EF] 25%). LV venting/decompression strategies had similar ECMO-related complication rates to non-vented patients. Patients who received IABP with ECMO (of whom the majority were in the eLV+ group ) had an improved post-decannulation survival relative to other venting strategies.