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Review
. 2019 Aug;49(8):657-677.
doi: 10.4070/kcj.2019.0188.

Clinical Pearls of Venoarterial Extracorporeal Membrane Oxygenation for Cardiogenic Shock

Min Suk Choi  1 , Kiick Sung  2 , Yang Hyun Cho  3
Affiliations
Review

Clinical Pearls of Venoarterial Extracorporeal Membrane Oxygenation for Cardiogenic Shock

Min Suk Choi et al. Korean Circ J. 2019 Aug.

Abstract

Extracorporeal membrane oxygenation (ECMO) is a technique that uses a pump to drain blood from a body, circulate blood through a membrane lung, and return the oxygenated blood back into the body. Venoarterial (VA) ECMO is a simplified version of the heart-lung machine that assists native pulmonary and/or cardiac function. VA ECMO is composed of a drainage cannula in the venous system and a return cannula in the arterial system. Because VA ECMO can increase tissue perfusion by increasing the arterial blood flow, it is used to treat medically refractory cardiogenic shock or cardiac arrest. VA ECMO has a distinct physiology that is referred to as differential flows. It can cause several complications such as left ventricular distension with pulmonary edema, distal limb ischemia, bleeding, and thromboembolism. Physicians who are using this technology should be knowledgeable on the prevention and management of these complications. We review the basic physiology of VA ECMO, the mechanism of complications, and the simple management of VA ECMO.

Keywords: Extracorporeal membrane oxygenation; Physiology; Postoperative complications; Shock.

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Conflict of interest statement

The authors have no financial conflicts of interest.

Figures

Figure 1
Figure 1. Schematic configuration of VA ECMO. The principal physiology of VA extracorporeal oxygenation of cardiopulmonary bypass.
ECMO = extracorporeal membrane oxygenation; RA = right atrium; VA = venoarterial.
Figure 2
Figure 2. Pressure-volume loops before and after VA ECMO. (A) Normal pressure-volume loop. (B) Representative pressure-volume loop as heart failure persists and deteriorates. (C) Impact of ECMO flow during VA ECMO. (D) Impact of decreasing PVR during VA ECMO. (E) Impact of inotropic agent during VA ECMO. (F) Impact of decreasing preload during VA ECMO. Modified from Burkhoff et al.
CGS = cardiogenic shock; ECMO = extracorporeal membrane oxygenation; LV = left ventricle; LVEDP = left ventricular end-diastolic pressure; LVSP = left ventricular systolic pressure; PVR = peripheral vascular resistance; VA = venoarterial.
Figure 3
Figure 3. A simplified diagram showing the physiology of VA ECMO. Harlequin syndrome is common during VA ECMO. Patients on VA ECMO often have lung failure caused by pulmonary edema with preexisting cardiogenic shock, combined pneumonia, ventilation-perfusion mismatch, and pulmonary edema by left ventricular distension. If mixing point is distal to the aortic arch, patients are at risk of cerebral ischemia.
ECMO = extracorporeal membrane oxygenation; RA = right atrium; VA = venoarterial.
Figure 4
Figure 4. LAVA ECMO. (A) In LAVA ECMO, the multistage cannula drains both in the left atrium (via end hole) and right atrium (via side holes). (B) A chest radiograph in which the cannula tip (red arrow) is placed in the left atrium through the atrial septum.
ECMO = extracorporeal membrane oxygenation; LAVA = left atrial venoarterial.
Figure 5
Figure 5. Simplified diagrams are showing interaction between a patient's native cardiovascular system and VA ECMO flow. Embolic stroke is usually caused by thrombi in the native cardiac chambers rather than extracorporeal circuit. Anticoagulation is more crucial at high-flow than low-flow ECMO.
ECMO = extracorporeal membrane oxygenation; VA = venoarterial.
Figure 6
Figure 6. The blood flow in a patient with pulmonary edema on VA ECMO is shown. If a patient has extremely poor left ventricular systolic function, IABP may increase cardiac afterload by systolic deflation and decrease cerebral perfusion by diastolic inflation.
ECMO = extracorporeal membrane oxygenation; IABP = intra-aortic balloon pump.
Figure 7
Figure 7. A simplified flow chart for the initial management of VA ECMO.
ECMO = extracorporeal membrane oxygenation; LV = left ventricle; MAP = mean arterial pressure; SaO2 = arterial oxygen saturation; SFA = superficial femoral artery; SvO2 = mixed venous oxygen saturation; VA = venoarterial.
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