ELSO Interim Guidelines for Venoarterial Extracorporeal Membrane Oxygenation in Adult Cardiac Patients

Over the past decade, the use of extracorporeal membrane oxygenation (ECMO) has increased exponentially, from approximately 30–40 patients per year in the United States 20 years ago, to over 2,000 per year currently, and rising.1 The increased utilization of ECMO has resulted from improved cannulation techniques, including percutaneous approach, as well as advances in the technology of the pumps, oxygenators, and cannulas. Despite these features, however, choosing appropriate candidates and managing their daily care can be extremely challenging. What follows is an in-depth discussion of the indications for venoarterial (VA) ECMO in adult patients affected by cardiac disease, the manner of its application, the physiology underlying the care for these patients, and the assessment and treatment of complications, including ethical and organizational issues. More in-depth material and information are provided in the Extracorporeal Life Support Organization (ELSO) 5th Edition Red Book.2 Furthermore, the recent ELSO indications about ECLS and cannulation nomenclature will be followed in this guideline.3,4 Decision Making in Adult VA ECMO for Acute Cardiac Failure VA ECMO may support patients for days or weeks as a “bridge-to-decision” that includes weaning after recovery of cardiac function, transplantation, long-term mechanical circulatory support (MCS), and withdrawal in the case of futility. Dedicated documents for the use of VA ECMO in the setting of cardiac arrest and postcardiotomy in adult patients are addressed by additional ELSO guidelines and as joint society position paper (expert consensus of EACTS/ELSO/STS/AATS).5 Indications Specific physiologic goals, monitoring, and patient selection. Cardiogenic shock suitable for ECMO is generally characterized by systemic systolic pressure less than 90, urine output 3) (normal is 5, shock is 2): O2 delivery is arterial oxygen content (normal 20 ml/dl) times cardiac output (normal 30 dl/m2/min). In VA ECMO access, addressing the goal is easy because the cardiac output is the ECMO flow and the arterial hemoglobin saturation is 100%, so content is easily calculated, knowing the hemoglobin concentration (normal 15 g/dl). In VA ECMO, the drainage blood saturation (the SVO2) measures the DO2:VO2 ratio, and SVO2 is measured continuously. If the arterial saturation is 100% and the venous sat is 80%, the ratio is 5:1. So, adjusting flow and hemoglobin to maintain SVO2 over 66% assures that the goal of DO2/VO2 > 3 is met. Additional details are described in the Red Book chapter on physiology.2 Table 1. - Clinical Features of Cardiogenic Shock and Defined Contemporary Trials and Guidelines Clinical Trial/Guidelines Cardiogenic Shock Criteria SHOCK Trial (1999) • SBP 90 mm Hg• Evidence of end-organ damage (UO 15 mm Hg IABP-SOAP II (2012) • MAP 2 mmol/L) EHS-PCI (2012) • SBP 90 mm Hg• Evidence of end-organ damage and increased filling pressure ESC-HF Guidelines (2016) • SBP 30 min or supportive intervention to maintain SBP >90 mm Hg• Evidence of end-organ damage (AMS, UO Cardiac or or or 30 of with massive and are not with the use of are to cannulation should be by with and the use of a will the of from to may be an increased for in the the and the to Percutaneous with may and when to an of percutaneous over cannulation has not shown and in this are Furthermore, as the of of is use of or for and is are and may in than of the Specific to the ECMO A of ECMO is the especially in the can to failure acute the pump in and massive to ECMO is after prolonged resuscitation should in a ECMO ECMO of of for of and with the of are in VA ECMO in a of the or of a clinical Specific to VA ECMO is that VA ECMO however, the is the in blood pressure to the flow in to a and, aortic valve or VA ECMO flow should be at the adequate and however, with increased myocardial pulmonary and in the left cardiac at ECMO on the a when the is by of the blood when the and is severe damage to the heart and can to blood and saturation be from the If of not the an additional to the may and can easily will the of the and with are to on and to be by of arterial blood after of ECMO including of and is for percutaneous In the of is should be in of ECMO flow and at the arterial or venous cannulation may and after ECMO The of a to the should be considered in the of oxygenation and refractory and should be at ECMO should be also to and VA ECMO VA ECMO weaning should be considered when patients cardiac the for support to maintain an adequate pulse pressure mm Hg mean arterial pressure of mm and sat at of VA ECMO should be of pump flow and weaning weaning is and to biventricular function, of as well as is a of cardiac output. be in this to and cardiac output with the VA ECMO VA ECMO flow is by 500 ml are after of no support or at of 1 of ECMO flow to of the and heart may not be when of the ECMO or is Trial is a weaning that can be The arterial flow is and 1 L of flow is to the and venous In with the this for assessment of weaning is the are MAP > mm > systolic mm and on of inotropes or inotropes and are as a weaning should to that are associated with ECMO are to from VA ECMO support days be considered for temporary support to for recovery as as systolic is with systolic before VA ECMO be considered for or heart for should be on the Society for and guidelines is of neurologic multiorgan age, or cancer as contraindications to durable support and heart transplantation and to these is with of care in patients are not candidates for is to with a and withdrawal of involvement of care should be considered in patients with VA ECMO to assist with of the of and for ECMO and decision for venoarterial extracorporeal membrane oxygenation and in patients with cardiogenic shock. CI, cardiac index; venous pressure; LVAD, left ventricular assist device; left ventricular MAP, mean arterial blood pressure; VA venoarterial extracorporeal life VA ECMO weaning should be considered when patients in the of ECLS including MAP > mm > systolic mm and on Trial or a the arterial and venous assessment with or ELSO support ECMO a of that ethical by of its to as a for The ECMO the to and the use of ECMO in a that not life also the ethical its use to the patient and or the and The and the The of is generally because the situations in ECMO is are that the for after its The be of this and of ECMO support and of appropriate care should in situations where ECMO is unlikely to be of or supportive care or may be of in these and support to are for decision The ECMO the ECMO can as a of in about the utilization of ECMO for of and by a can of the of the to and of ECMO should be The Society In ECLS is not a to or the with the of the of ECMO to support patients is in clinical the evidence to support its use is to this is the of its in and the on to with the of of ECMO has to be and in clinical the of ECMO, decision should the of myocardial and, the of bridging to durable MCS or of the should a discussion of the the of bridging to and be a of support should recovery not in with the patient’s ECMO in the care of these patients should be in on this of a with should be for to and be of the ECMO We and the ELSO for in the