Venting during venoarterial extracorporeal membrane oxygenation.
Enzo Lüsebrink, Leonhard Binzenhöfer, Antonia Kellnar, Christoph Müller, Clemens Scherer, Benedikt Schrage, Dominik Joskowiak, Tobias Petzold, Daniel Braun, Stefan Brunner, Sven Peterss, Jörg Hausleiter, Sebastian Zimmer, Frank Born, Dirk Westermann, Holger Thiele, Andreas Schäfer, Christian Hagl, Steffen Massberg, Martin Orban
Author Information
Enzo Lüsebrink: Cardiac Intensive Care Unit, Medizinische Klinik Und Poliklinik I, Klinikum Der Universität München, Marchioninistraße 15, 81377, Munich, Germany. ORCID
Leonhard Binzenhöfer: Cardiac Intensive Care Unit, Medizinische Klinik Und Poliklinik I, Klinikum Der Universität München, Marchioninistraße 15, 81377, Munich, Germany.
Antonia Kellnar: Cardiac Intensive Care Unit, Medizinische Klinik Und Poliklinik I, Klinikum Der Universität München, Marchioninistraße 15, 81377, Munich, Germany.
Christoph Müller: Herzchirurgische Klinik Und Poliklinik, Klinikum Der Universität München, Munich, Germany.
Clemens Scherer: Cardiac Intensive Care Unit, Medizinische Klinik Und Poliklinik I, Klinikum Der Universität München, Marchioninistraße 15, 81377, Munich, Germany.
Benedikt Schrage: Department of Cardiology, University Heart and Vascular Center Hamburg, Hamburg, Germany.
Dominik Joskowiak: Herzchirurgische Klinik Und Poliklinik, Klinikum Der Universität München, Munich, Germany.
Tobias Petzold: Cardiac Intensive Care Unit, Medizinische Klinik Und Poliklinik I, Klinikum Der Universität München, Marchioninistraße 15, 81377, Munich, Germany.
Daniel Braun: Cardiac Intensive Care Unit, Medizinische Klinik Und Poliklinik I, Klinikum Der Universität München, Marchioninistraße 15, 81377, Munich, Germany.
Stefan Brunner: Cardiac Intensive Care Unit, Medizinische Klinik Und Poliklinik I, Klinikum Der Universität München, Marchioninistraße 15, 81377, Munich, Germany.
Sven Peterss: Herzchirurgische Klinik Und Poliklinik, Klinikum Der Universität München, Munich, Germany.
Jörg Hausleiter: Cardiac Intensive Care Unit, Medizinische Klinik Und Poliklinik I, Klinikum Der Universität München, Marchioninistraße 15, 81377, Munich, Germany.
Sebastian Zimmer: Medizinische Klinik Und Poliklinik II, Universitätsklinikum Bonn, Bonn, Germany.
Frank Born: Herzchirurgische Klinik Und Poliklinik, Klinikum Der Universität München, Munich, Germany.
Dirk Westermann: Department of Cardiology, University Heart and Vascular Center Hamburg, Hamburg, Germany.
Holger Thiele: Department of Internal Medicine/Cardiology and Leipzig Heart Institute, Heart Center Leipzig at University of Leipzig, Leipzig, Germany.
Andreas Schäfer: Klinik Für Kardiologie Und Angiologie, Medizinische Hochschule Hannover, Hannover, Germany.
Christian Hagl: Herzchirurgische Klinik Und Poliklinik, Klinikum Der Universität München, Munich, Germany.
Steffen Massberg: Cardiac Intensive Care Unit, Medizinische Klinik Und Poliklinik I, Klinikum Der Universität München, Marchioninistraße 15, 81377, Munich, Germany.
Martin Orban: Cardiac Intensive Care Unit, Medizinische Klinik Und Poliklinik I, Klinikum Der Universität München, Marchioninistraße 15, 81377, Munich, Germany. MartinOrban@gmail.com.
Cardiogenic shock and cardiac arrest contribute pre-dominantly to mortality in acute cardiovascular care. Here, veno-arterial extracorporeal membrane oxygenation (VA-ECMO) has emerged as an established therapeutic option for patients suffering from these life-threatening entities. VA-ECMO provides temporary circulatory support until causative treatments are effective and enables recovery or serves as a bridging strategy to surgical ventricular assist devices, heart transplantation or decision-making. However, in-hospital mortality rate in this treatment population is still around 60%. In the recently published ARREST trial, VA-ECMO treatment lowered mortality rate in patients with ongoing cardiac arrest due to therapy refractory ventricular fibrillation compared to standard advanced cardiac life support in selected patients. Whether VA-ECMO can reduce mortality compared to standard of care in cardiogenic shock has to be evaluated in the ongoing prospective randomized studies EURO-SHOCK (NCT03813134) and ECLS-SHOCK (NCT03637205). As an innate drawback of VA-ECMO treatment, the retrograde aortic flow could lead to an elevation of left ventricular (LV) afterload, increase in LV filling pressure, mitral regurgitation, and elevated left atrial pressure. This may compromise myocardial function and recovery, pulmonary hemodynamics-possibly with concomitant pulmonary congestion and even lung failure-and contribute to poor outcomes in a relevant proportion of treated patients. To overcome these detrimental effects, a multitude of venting strategies are currently engaged for both preventive and emergent unloading. This review aims to provide a comprehensive and structured synopsis of existing venting modalities and their specific hemodynamic characteristics. We discuss in detail the available data on outcome categories and complication rates related to the respective venting option.
