Prone Positioning During ECPELLA Support for Cardiogenic Shock: A Single-Center Retrospective Study

Background: Prone positioning improves oxygenation in acute respiratory distress syndrome, but its feasibility and safety in patients with cardiogenic shock supported by combined venoarterial extracorporeal membrane oxygenation and percutaneous transvalvular microaxial flow pump (ECPELLA) remain unclear. Methods: We retrospectively reviewed 65 consecutive patients receiving ECPELLA between February 2020 and August 2024. Fifteen patients underwent prone positioning for hypoxemic respiratory failure, in which dorsal atelectasis was considered a major contributing factor. Respiratory parameters, including PaO₂/FiO₂ ratio and dynamic lung compliance, as well as hemodynamic variables, were assessed before and after prone positioning. Results: Prone positioning was initiated a median of 2 days after ECPELLA initiation, with a median cumulative duration of 32 h. PaO₂/FiO₂ improved from 145 (IQR, 80-177) to 308 (IQR, 260-375; p < 0.0001). Cdyn increased modestly from 33 (IQR, 28-37) to 35 (IQR, 33-50) mL/cmH₂O (p = 0.03). Hemodynamic parameters remained stable. One patient (6.7%) experienced bleeding at the ECMO cannulation site, controlled with a purse-string suture. Pressure ulcers occurred in four patients (stage 1-2) and were managed conservatively. Conclusions: Prone positioning during ECPELLA support was feasible and associated with improved oxygenation without significant hemodynamic compromise. Observed complications were manageable. These findings suggest prone positioning may serve as a supportive respiratory strategy in selected cardiogenic shock patients on ECPELLA. Prospective multicenter studies are warranted to confirm these results.