Extracorporeal life support devices and strategies for management of acute cardiorespiratory failure in adult patients: a comprehensive review

Abstract

Evolution of extracorporeal life support (ECLS) technology has added a new dimension to the intensive care management of acute cardiac and/or respiratory failure in adult patients who fail conventional treatment. ECLS also complements cardiac surgical and cardiology procedures, implantation of long-term mechanical cardiac assist devices, heart and lung transplantation and cardiopulmonary resuscitation. Available ECLS therapies provide a range of options to the multidisciplinary teams who are involved in the time-critical care of these complex patients. While venovenous extracorporeal membrane oxygenation (ECMO) can provide complete respiratory support, extracorporeal carbon dioxide removal facilitates protective lung ventilation and provides only partial respiratory support. Mechanical circulatory support with venoarterial (VA) ECMO employed in a traditional central/peripheral fashion or in a temporary ventricular assist device configuration may stabilise patients with decompensated cardiac failure who have evidence of end-organ dysfunction, allowing time for recovery, decision-making, and bridging to implantation of a long-term mechanical circulatory support device and occasionally heart transplantation. In highly selected patients with combined severe cardiac and respiratory failure, advanced ECLS can be provided with central VA ECMO, peripheral VA ECMO with timely transition to venovenous ECMO or VA-venous ECMO upon myocardial recovery to avoid upper body hypoxia or by addition of an oxygenator to the temporary ventricular assist device circuit. This article summarises the available ECLS options and provides insights into the principles and practice of these techniques. One should emphasise that, as is common with many emerging therapies, their optimal use is currently not backed by quality evidence. This deficiency needs to be addressed to ensure that the full potential of ECLS can be achieved.

Figure 1

Interventional lung assist device (iLA™; NovaLung GmbH, Talheim, Germany) for pumpless arterio-venous carbon dioxide removal. Reproduced with permission from [27].

Figure 2

Venoarterial extracorporeal membrane oxygenation. Venoarterial extracorporeal membrane oxygenation can be instituted: (a) centrally by cannulating the right atrium/inferior venacava and the aorta; (b) peripherally using the femoral vein and femoral artery (solid arrow, arterial return cannula; hollow arrow, back-flow cannula for distal limb perfusion); or (c) peripherally using the axillary/subclavian artery. The choice is often guided by the clinical setting, the expected duration of support and pulmonary function.

Figure 3

Biventricular assist device along with respiratory support provided by the oxygenator in the circuit. The hybrid Centrimag™ (Levitronix LLC, Waltham, MA, USA) extracorporeal membrane oxygenation system can be used as a biventricular assist device along with respiratory support provided by the oxygenator in the circuit. Reproduced with permission from [47]. LVAD, left ventricular assist device; RA, right atrium.

Figure 4

From venoarterial extracorporeal membrane oxygenation (ECMO) to use of ECMO as a temporary ventricular assist device. (A) Emergent femoro-femoral venoarterial extracorporeal membrane oxygenation. (B) Left ventricular apical cannulation and decompression. (C) Right ventricular recovery and isolated temporary left ventricular support. (D) Axillary artery cannulation to facilitate mobilisation. Reproduced with permission from [48].

Figure 5

Patient in extremis initially receiving femoro-femoral venoarterial extracorporeal membrane oxygenation (ECMO) with transition to venovenous ECMO. Patient in extremis initially received femoro-femoral venoarterial (VA) ECMO for severe cardiorespiratory failure with transition to venovenous (VV) ECMO on day 4 following satisfactory cardiac recovery. (a) Chest X-ray scan shows multistage access cannula in the right atrium (RA) during VA ECMO, (b) which was later withdrawn into the inferior vena cava (IVC) during VV ECMO. (b) A venous return cannula can also be seen in the right atrium.