Key result
Stepwise increases in VA-ECMO flow from 2 to 4 L/min resulted in decreased pulmonary capillary wedge pressure in 36% of patients, stable pressure in 58%, and an increase in only 6%.
Why the study?
Does stepwise variation of femoro-femoral VA-ECMO flow affect pulmonary capillary wedge pressure in patients with cardiogenic shock?
Does stepwise variation of femoro-femoral VA-ECMO flow affect pulmonary capillary wedge pressure in patients with cardiogenic shock?
Increasing VA-ECMO flow from 2 to 4 L/min has a neutral effect on PCWP in most cardiogenic shock patients and decreases it in about one-third, challenging the assumption that higher flows consistently exacerbate pulmonary edema.
BACKGROUND The hemodynamic effects of femoro-femoral venoarterial (VA) extracorporeal membrane oxygenation (ECMO) on pulmonary capillary wedge pressure (PCWP) remain poorly defined. High ECMO flow is believed to increase PCWP and the risk of pulmonary edema; yet, supporting in vivo physiological data are lacking. OBJECTIVES The purpose of this study was to evaluate the impact of incremental femoro-femoral VA-ECMO flow variations on PCWP, hemodynamic, and echocardiographic parameters in patients with cardiogenic shock during the early phase of VA-ECMO support, after stabilization. METHODS This prospective, single-center interventional study was conducted at Pitié-Salpêtrière Hospital, Paris, France. The ECMO-Flow trial consisted of stepwise VA-ECMO flow variations from 2 to 4 L/min in 0.5-L/min increments. Hemodynamic assessment included pulmonary artery catheter measurements, transthoracic echocardiography, and blood gas analyses. RESULTS A total of 80 patients were included. At baseline, 27 patients (34%) had PCWP ≥18 mm Hg. Left ventricular (LV) dilation, mitral regurgitation, elevated central venous pressure (CVP), and preserved right ventricular (RV) function were associated with higher baseline PCWP. During the ECMO-Flow trial, PCWP decreased in 29 patients (36%), remained stable in 46 (58%), and increased in only 5 (6%), despite a concomitant rise in LV afterload. CVP significantly decreased, while RV afterload remained unchanged. Indexed stroke volume decreased and myocardial work remained stable despite an increase in LV afterload. Throughout the ECMO-flow trial, a significant PCWP decrease was observed in patients with better baseline LV and RV function and lower CVP. CONCLUSIONS As VA-ECMO flow increases, the expected rise in PCWP caused by afterload elevation appears to be counterbalanced by a reduction in RV preload, resulting in a neutral effect in most patients, a significant PCWP decrease in approximately one-third, and an only infrequent increase.
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Saura et al. (2025) studied Cardiogenic shock (n=80). Stepwise VA-ECMO flow variations was evaluated on Impact of incremental femoro-femoral VA-ECMO flow variations on pulmonary capillary wedge pressure (PCWP). Stepwise increases in VA-ECMO flow from 2 to 4 L/min resulted in decreased pulmonary capillary wedge pressure in 36% of patients, stable pressure in 58%, and an increase in only 6%.
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