Emerging concepts in heart failure management and treatment: circulatory support with extracorporeal membrane oxygenation (ECMO)

Effects of Concomitant Intra-Aortic Balloon Pump Usage and Different Cannulation Techniques on Venoarterial Extracorporeal Membrane Oxygenation Support in Terms of Organ Perfusion

INTRODUCTION

Various cannulation strategies for venoarterial extracorporeal membrane oxygenation (V-A ECMO) support are currently in use according to the clinical urgency and experience of the rescuing team. Although central V-A ECMO is considered more effective than a peripheral approach, the superiority of one cannulation configuration instead of another remains a controversial subject. This study mainly aims to compare the contribution of V-A ECMO circulatory support modalities to patients' improvement according to various cannulation site strategies and additional usage of intra-aortic balloon pump (IABP).

METHODS

The study design involved the categorization of all patients into two groups: isolated V-A ECMO support and V-A ECMO plus IABP support. Secondly, we divided the patients into four groups considering V-A ECMO cannulation sites, such as central (aorto-atrial), axillo-femoral, femoro-femoral, and jugulo-femoral. We analyzed the parameters regarding the outcome for each group.

RESULTS

When comparing cannulation sites in relation to laboratory parameters for assessing organ perfusion, no statistically significant differences were observed among the groups. We found no statistically significant result within the groups affecting organ perfusion. The complication rates were higher in patients with concomitant IABP support, but the difference was not statistically significant likewise.

CONCLUSION

V-A ECMO provides effective perfusion, no matter which cannulation site is preferred during the decision-making process, and the utilization of IABP support has no additional contribution to the outcomes. We believe that the most suitable strategy should be a tailor-made decision according to the clinical status of patients, the pathology, urgency, and cost-effectiveness.

Vascular Complications in Extracorporeal Membrane Oxygenation-A Narrative Review

The establishment of a peripheral ECMO circuit can lead to significant arterial and venous complications in 10-30% of patients. Vascular complications, particularly acute limb ischemia, are associated with worsening overall outcomes. Limb ischemia occurs significantly more frequently in the early stages of VA ECMO than in VV ECMO. Mechanisms of limb ischemia include arterial obstruction, cannulation injury, loss of pulsatile flow, thromboembolism, venous stasis from compressive obstruction with large venous cannulas, and systemic vasoconstriction due to shock and pharmacologic vasoconstriction. The care team may use several mitigation strategies to prevent limb ischemia. Arterial and venous complications can be mitigated by careful access site selection, minimizing cannula size, placement of distal perfusion and/or outflow catheter(s), and continuous NIRS monitoring. Rapid intervention, when ischemia or compartment syndrome occurs, can reduce limb loss but may not affect the mortality and morbidity of the ECMO patient in the long term due to their underlying conditions and the etiology of the ECMO need.

Multimodality Imaging in Advanced Heart Failure for Diagnosis, Management and Follow-Up: A Comprehensive Review

Advanced heart failure (AHF) presents a complex landscape with challenges spanning diagnosis, management, and patient outcomes. In response, the integration of multimodality imaging techniques has emerged as a pivotal approach. This comprehensive review delves into the profound significance of these imaging strategies within AHF scenarios. Multimodality imaging, encompassing echocardiography, cardiac magnetic resonance imaging (CMR), nuclear imaging and cardiac computed tomography (CCT), stands as a cornerstone in the care of patients with both short- and long-term mechanical support devices. These techniques facilitate precise device selection, placement, and vigilant monitoring, ensuring patient safety and optimal device functionality. In the context of orthotopic cardiac transplant (OTC), the role of multimodality imaging remains indispensable. Echocardiography offers invaluable insights into allograft function and potential complications. Advanced methods, like speckle tracking echocardiography (STE), empower the detection of acute cell rejection. Nuclear imaging, CMR and CCT further enhance diagnostic precision, especially concerning allograft rejection and cardiac allograft vasculopathy. This comprehensive imaging approach goes beyond diagnosis, shaping treatment strategies and risk assessment. By harmonizing diverse imaging modalities, clinicians gain a panoramic understanding of each patient's unique condition, facilitating well-informed decisions. The aim is to highlight the novelty and unique aspects of recently published papers in the field. Thus, this review underscores the irreplaceable role of multimodality imaging in elevating patient outcomes, refining treatment precision, and propelling advancements in the evolving landscape of advanced heart failure management.