What question did this study set out to answer?

The aim is to explore an integrated approach using specific hemodynamic measures to guide VA-ECMO decisions in right ventricular infarction.

March 28, 2026Open Access

Integrated Echo-Hemodynamic Framework for VA-ECMO in Right Ventricular Infarction

Key Result

Integrating pulmonary artery pulsatility index and coupling ratios guides VA-ECMO management in right ventricular infarction, with successful weaning achieved when PAPI exceeds 1.5.

Key Points

The aim is to explore an integrated approach using specific hemodynamic measures to guide VA-ECMO decisions in right ventricular infarction.
Analysis of 3 clinical cases involving RV myocardial infarction and cardiogenic shock.
Evaluation of pulmonary artery pulsatility index (PAPI) and RV-pulmonary artery coupling ratios.
Assessment of the efficacy of inhaled nitric oxide (iNO)
Monitoring hemodynamic parameters pre and post-ECMO initiation.
PAPI levels above 1.5 allowed successful ECMO weaning in cases 1 and 2.
Case 3 was conservatively managed with a PAPI of 1.05 without requiring ECMO.
Inhaled nitric oxide improved PAPI during weaning in case 2 but caused deterioration in case 3.
Coupling ratios supplemented PAPI findings, providing a more reliable assessment for clinical decision-making.

Structured PICO

Does an integrated echo-hemodynamic framework using PAPI and RV-PA coupling ratios help guide VA-ECMO decision-making in patients with RV myocardial infarction and cardiogenic shock?

Population

3 patients with right ventricular (RV) myocardial infarction complicated by cardiogenic shock

Intervention

Integrated echo-hemodynamic approach combining pulmonary artery pulsatility index (PAPI) and RV-pulmonary artery coupling ratios (tricuspid annular systolic velocity/PASP, TAPSE/PASP) for VA-ECMO decision-making

Outcome

VA-ECMO initiation and weaning success

Integrating PAPI and RV-PA coupling ratios provides complementary information on hemodynamic reserve and intrinsic RV function to guide VA-ECMO initiation and weaning in RV infarction.

Main Result

Absolute Event Rate: 0% vs 0%

Abstract

Right ventricular (RV) myocardial infarction with cardiogenic shock presents complex management challenges. We present 3 cases illustrating a potential integrated approach combining pulmonary artery pulsatility index (PAPI) and RV-pulmonary artery coupling ratios (tricuspid annular systolic velocity/pulmonary artery systolic pressure, tricuspid annular plane systolic excursion/pulmonary artery systolic pressure) for venoarterial extracorporeal membrane oxygenation decision-making. Case 1 (PAPI = 0.47) and case 2 (PAPI = 0.64) required venoarterial extracorporeal membrane oxygenation with successful weaning when PAPI exceeded 1.5. Case 3 (PAPI = 1.05) was managed conservatively. In case 2, inhaled nitric oxide (iNO) improved PAPI during weaning. In case 3, iNO caused paradoxical deterioration necessitating discontinuation. Based on these observations, we suggest that PAPI and coupling ratios provide complementary information: PAPI reflects hemodynamic reserve, whereas coupling ratios assess intrinsic RV function. Neither parameter alone is sufficient; integration of both guides clinical decisions. Prospective validation is needed. For iNO use without mechanical support, adequate left ventricular reserve is critical; PAPI decline mandates immediate discontinuation.