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Published on: January 17, 2025
National Practice Patterns of VA ECMO and Left Ventricular Mechanical Unloading for Cardiogenic Shock
Dustin M Anderson-Bell1, Morgan M Millar2, Rachel R Codden2
1Division of Respiratory, Critical Care, and Occupational Pulmonary Medicine, Department of Medicine, University of Utah Health, Salt Lake City, Utah, USA.
Insights
Management of cardiogenic shock (CS) with Venoarterial Extracorporeal Membrane Oxygenation (VA ECMO) varies widely. This study reveals significant heterogeneity in VA ECMO use and Left Ventricular Mechanical Unloading (LVMU) strategies, highlighting the need for standardized approaches.
Area of Science:
- Cardiology
- Critical Care Medicine
- Mechanical Circulatory Support
Background:
- Cardiogenic shock (CS) presents a significant clinical challenge with high morbidity.
- Venoarterial Extracorporeal Membrane Oxygenation (VA ECMO) is a key therapy for CS.
- Optimal strategies for VA ECMO in CS, particularly regarding Left Ventricular Mechanical Unloading (LVMU), lack consensus.
Purpose of the Study:
- To survey current practice patterns in the management of CS using VA ECMO.
- To characterize the variability in VA ECMO implementation and LVMU strategies across institutions.
Main Methods:
- A national survey was distributed to physicians managing VA ECMO for CS.
- Data from 67 institutions were analyzed to assess practice variations.
Main Results:
- VA ECMO was used for a median of 10% of CS patients.
- Formal shock teams were present in 64.1% of centers, associated with higher VA ECMO volume.
- LVMU was employed by 63.4% of centers, most frequently with Impella, but with wide variation in initiation timing and targets.
Conclusions:
- Substantial heterogeneity exists in CS diagnosis, VA ECMO initiation, and LVMU strategies.
- These findings underscore the necessity for prospective research to establish optimal patient care protocols.
Background:
Cardiogenic shock (CS) remains highly morbid despite significant advancements in management. A cornerstone of this management is Venoarterial Extracorporeal Membrane Oxygenation (VA ECMO). However, consensus surrounding the management of VA ECMO for CS, including the use of concomitant Left Ventricular Mechanical Unloading (LVMU), remains limited.
Methods:
We thus conducted a national survey of practice patterns in the treatment of CS to characterize such variability. Surveys were distributed to physicians involved in management of VA ECMO across a variety of center types.
Results:
Responses representing 67 institutions were analyzed. VA ECMO was used for a median of 10% of CS patients at each institution. Formal shock teams were present at 64.1% of centers and were associated with both higher annual VA ECMO volume (P⟨0.01) and greater intra-aortic balloon pump use prior to VA ECMO (p = 0.03). LVMU was employed by 63.4% of centers, most commonly using Impella (93.3%), with unloading initiated at ECMO cannulation in a median of 30% of cases. Triggers and targets for LVMU varied widely, though pulmonary capillary wedge pressure was the most common endpoint.
Conclusions:
These findings highlight substantial heterogeneity in CS diagnosis, VA ECMO initiation, and LVMU strategies, underscoring the need for prospective studies to define optimal care.
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