Transfer of Patients With Cardiogenic Shock Using Veno-Arterial Extracorporeal Membrane Oxygenation

The challenge of advanced therapies in the contemporary era: first in Europe ECPELLA long-distance transfer-a case report

Background

The use of mechanical circulatory support (MCS) has markedly increased over the last decade, so have the inter-hospital transfers, with the aim of being able to offer advanced heart failure (AHF) therapies and centralizing patients to tertiary centres.

Case summary

In this article, we present the first in Europe long-distance air transfer of a patient supported by veno-arterial extracorporeal membrane oxygenator and Impella (ECPELLA), as a bridge to successful heart transplant. In our case report, a foreign young patient with AHF due to familiar cardiomyopathy required multiple MCS devices to achieve cardiovascular stability. After appropriate planning and multidisciplinary discussion, the patient was transferred on MCS to his country of origin via a fixed-wing airplane, in order to be assessed for heart transplantation. During take-off, the Impella flows temporarily dropped and a suction alarm was displayed; however, this rectified without intervention, and the rest of the flight was uneventful. One month after transfer, the patient underwent successful heart transplantation and remained clinically stable during the 12-month follow-up.

Discussion

Our experience links together the current challenges in the evolving AHF strategies and the increased need for inter-facility cooperation. Both these clinical and logistic challenges appear to lead to possible improved outcomes, after appropriate assessment, training, and accurate planning. Our experience provides useful information on feasibility of long-distance transport of patients supported by ECPELLA in Europe.

Extracorporeal Membrane Oxygenation (VA-ECMO) in Management of Cardiogenic Shock

Cardiogenic shock is a critical condition of low cardiac output resulting in insufficient systemic perfusion and end-organ dysfunction. Though significant advances have been achieved in reperfusion therapy and mechanical circulatory support, cardiogenic shock continues to be a life-threatening condition associated with a high rate of complications and excessively high patient mortality, reported to be between 35% and 50%. Extracorporeal membrane oxygenation can provide full cardiopulmonary support, has been increasingly used in the last two decades, and can be used to restore systemic end-organ hypoperfusion. However, a paucity of randomized controlled trials in combination with high complication and mortality rates suggest the need for more research to better define its efficacy, safety, and optimal patient selection. In this review, we provide an updated review on VA-ECMO, with an emphasis on its application in cardiogenic shock, including indications and contraindications, expected hemodynamic and echocardiographic findings, recommendations for weaning, complications, and outcomes. Furthermore, specific emphasis will be devoted to the two published randomized controlled trials recently presented in this setting.

Time for a rethink in cardiogenic shock: the shock to survival framework document

Cardiogenic shock remains a time-critical, complex syndrome that continues to present challenges to clinicians and healthcare systems. Despite advances in the fields of cardiovascular and critical care medicine, mortality remains high. This article summarises the recent shock to survival document, which outlined the current and ideal future state of cardiogenic shock care nationally to improve patient outcomes. Shock to survival emphasises the need for education and training in the early recognition of the hypoperfusion that is pathognomomic of cardiogenic shock. Improved provision of focused cardiac ultrasound is essential to confirm a cardiac cause. Early identification of the patient with cardiogenic shock should be supported by access to defined pathways of care, including specialist shock centres and multiprofessional teams with domain expertise and the capability to manage the myriad of causative aetiologies. Given the absence of high-quality data to inform practice nationally, robust datasets are an unmet need to inform best practice, guide design of clinical services and pathways and drive innovation through research and clinical trials.

Impella Versus VA-ECMO for Patients with Cardiogenic Shock: Comprehensive Systematic Literature Review and Meta-Analyses

Impella and VA-ECMO are two possible therapeutic courses for the treatment of patients with cardiogenic shock (CS). The study aims to perform a systematic literature review and meta-analyses of a comprehensive set of clinical and socio-economic outcomes observed when using Impella or VA-ECMO with patients under CS. A systematic literature review was performed in Medline, and Web of Science databases on 21 February 2022. Nonoverlapping studies with adult patients supported for CS with Impella or VA-ECMO were searched. Study designs including RCTs, observational studies, and economic evaluations were considered. Data on patient characteristics, type of support, and outcomes were extracted. Additionally, meta-analyses were performed on the most relevant and recurring outcomes, and results shown using forest plots. A total of 102 studies were included, 57% on Impella, 43% on VA-ECMO. The most common outcomes investigated were mortality/survival, duration of support, and bleeding. Ischemic stroke was lower in patients treated with Impella compared to the VA-ECMO population, with statistically significant difference. Socio-economic outcomes including quality of life or resource use were not reported in any study. The study highlighted areas where further data collection is needed to clarify the value of complex, new technologies in the treatment of CS that will enable comparative assessments focusing both on the health impact on patient outcomes and on the financial burden for government budgets. Future studies need to fill the gap to comply with recent regulatory updates at the European and national levels.

Cardiogenic Shock: Protocols, Teams, Centers, and Networks

The mortality of cardiogenic shock (CS) remains unacceptably high. Delays in the recognition of CS and access to disease-modifying or hemodynamically stabilizing interventions likely contribute to poor outcomes. In parallel to successful initiatives in other disease states, such as acute ST-elevation MI and major trauma, institutions are increasingly advocating the use of a multidisciplinary ‘shock team’ approach to CS management. A volume–outcome relationship exists in CS, as with many other acute cardiovascular conditions, and the emergence of ‘shock hubs’ as experienced facilities with an interest in improving CS outcomes through a hub-and-spoke ‘shock network’ approach provides another opportunity to deliver improved CS care as widely and equitably as possible. This narrative review outlines improvements from a networked approach to care, discusses a team-based and protocolized approach to CS management, reviews the available evidence and discusses the potential benefits, challenges, and opportunities of such systems of care.

Evaluation and management of patients with chronic thromboembolic pulmonary hypertension - consensus statement from the ISHLT

ISHLT members have recognized the importance of a consensus statement on the evaluation and management of patients with chronic thromboembolic pulmonary hypertension. The creation of this document required multiple steps, including the engagement of the ISHLT councils, approval by the Standards and Guidelines Committee, identification and selection of experts in the field, and the development of 6 working groups. Each working group provided a separate section based on an extensive literature search. These sections were then coalesced into a single document that was circulated to all members of the working groups. Key points were summarized at the end of each section. Due to the limited number of comparative trials in this field, the document was written as a literature review with expert opinion rather than based on level of evidence.

Regional extracorporeal membrane oxygenation retrieval service during the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic: an interdisciplinary team approach to maintain service provision despite increased demand

OBJECTIVES

Coronavirus disease 2019 is a new contagious disease that has spread rapidly across the world. It is associated with high mortality in those who develop respiratory complications and require admission to intensive care. Extracorporeal membrane oxygenation (ECMO) is a supportive therapy option for selected severely ill patients who deteriorate despite the best supportive care. During the coronavirus disease 2019 pandemic, extra demand led to staff reorganization; hence, cardiac surgery consultants joined the ECMO retrieval team. This article describes how we increased service provisions to adapt to the changes in activity and staffing.

METHODS

The data were collected from 16 March 2020 to 8 May 2020. The patients were referred through a dedicated Web-based referral portal to cope with increasing demand. The retrieval team attended the referring hospital, reviewed the patients and made the final decision to proceed with ECMO.

RESULTS

We reported 41 ECMO retrieval runs during this study period. Apart from staffing changes, other retrieval protocols were maintained. The preferred cannulation method for veno-venous ECMO was drainage via the femoral vein and return to the right internal jugular vein. There were no complications reported during cannulation or transport.

CONCLUSIONS

Staff reorganization in a crisis is of paramount importance. For those with precise transferrable skills, experience can be gained quickly with appropriate supervision. Therefore, the team members were selected based on skill mix rather than on roles that are more traditional. We have demonstrated that an ECMO retrieval service can be reorganized swiftly and successfully to cope with the sudden increase in demand by spending cardiac surgeons services to supplement the anaesthetic-intensivist roles.