Our Experience in Using Extracorporeal Membrane Oxygenation in Patients with Refractory Cardiogenic Shock

Background Veno-arterial extracorporeal membrane oxygenation (VA ECMO) is a critical care treatment option for patients with refractory cardiogenic shock. This method of temporary support of the cardiorespiratory system gives us and the patient time to restore organ function or is a «bridge» to other methods of treatment. Nevertheless, the issue of identifying the optimal time for VA ECMO implantation in patients with acute myocardial infarction complicated by refractory cardiogenic shock remains relevant.

Aim To evaluate the efficiency of extracorporeal membrane oxygenation in various clinical situations in patients with acute myocardial infarction complicated by refractory cardiogenic shock and post-infarction damage to the valves of the heart.

Material and method We present 3 patients with acute coronary syndrome complicated by refractory cardiogenic shock, of different age groups and comorbidities, who underwent veno-arterial extracorporeal oxygenation in various SCAI shock stages, and mechanical complications associated with acute myocardial infarction.

Results In all the cases, stabilization of hemodynamics and heart function was achieved, and there were no hypoxic disorders of organs. In one case, a hemorrhagic complication associated with the VA ECMO procedure was noted. In one case, VA ECMO was performed as an intermediate stage for the correction of post-infarction mitral valve injury.

Conclusion These clinical cases demonstrate the efficiency of the timely start of VA ECMO before the development of organ dysfunction, which allows restoring myocardial function, and helps maintain hemodynamic normalization before the cardiac surgical stage of treatment.

1. Featherstone PJ, Ball CM. The early history of extracorporeal membrane oxygenation. Anaesth Intensive Care. 2018;46(6):555–557. PMID: 30447660 https://doi.org/10.1177/0310057X1804600601

2. Hill JD, O’Brien TG, Murray JJ, Dontigny L, Bramson ML, Osborn JJ, et al. Prolonged extracorporeal oxygenation for acute post-traumatic respiratory failure (shock-lung syndrome) use of the Bramson membrane lung. New Engl J Med. 1972;286(12):629–634. PMID: 5060491 https://doi.org/10.1056/NEJM197203232861204

3. Thiele H, Akin I, Sandri M, Fuernau G, de Waha S, Meyer-Saraei R, et al. PCI strategies in patients with acute myocardial infarction and cardiogenic shock. N Engl J Med. 2017;377(25):2419–2432. PMID: 29083953 https://doi.org/10.1056/NEJMoa1710261

4. Rao P, Khalpey Z, Smith R, Burkhoff D, Kociol RD. Venoarterial extracorporeal membrane oxygenation for cardiogenic shock and cardiac arrest. Circ Heart Fail. 2018;11:e004905. PMID: 30354364 https://doi.org/10.1161/CIRCHEARTFAILURE.118.004905

5. Reyentovich A, Barghash MH, Hochman JS. Management of refractory cardiogenic shock. Nat Rev Cardiol. 2016;13(8):481–492. PMID: 27356877 https://doi.org/10.1038/nrcardio.2016.96

6. Flaherty MP, Khan AR, O’Neill WW. Early initiation of Impella in acute myocardial infarction complicated by cardiogenic shock improves survival: a meta-analysis. J Am Coll Cardiol Intv. 2017;10(17):1805– 1806. PMID: 28882288 https://doi.org/10.1016/j.jcin.2017.06.027

7. Naidu SS, Baran DA, Jentzer JC, Hollenberg SM, van Diepen S, Basir MB, et al. SCAI SHOCK Stage Classification Expert Consensus Update: A Review and Incorporation of Validation Studies: This statement was endorsed by the American College of Cardiology (ACC), American College of Emergency Physicians (ACEP), American Heart Association (AHA), European Society of Cardiology (ESC) Association for Acute Cardiovascular Care (ACVC), International Society for Heart and Lung Transplantation (ISHLT), Society of Critical Care Medicine (SCCM), and Society of Thoracic Surgeons (STS) in December 2021. J Am Coll Cardiol. 2022;79(9):933–946. PMID: 35115207 https://doi.org/10.1016/j.jacc.2022.01.018

8. Stretch R, Sauer CM, Yuh DD, Bonde P. National trends in the utilization of short-term mechanical circulatory support: incidence, outcomes, and cost analysis. J Am Coll Cardiol. 2014;64(14):1407–1415. PMID:25277608 https://doi.org/10.1016/j.jacc.2014.07.958

9. Schmidt M, Burrell A, Roberts L, Bailey M, Sheldrake J, Rycus PT, et al. Predicting survival after ECMO for refractory cardiogenic shock: the survival after veno-arterial-ECMO (SAVE)-score. Eur Heart J. 2015;36(33):2246–2256. PMID: 26033984 https://doi.org/10.1093/eurheartj/ehv194

10. Combes A, Leprince P, Luyt CE, Bonnet N, Trouillet J-L, Léger P, et al. Outcomes and long-term quality-of-life of patients sup-ported by extracorporeal membrane oxygenation for refractory cardiogenic shock. Crit Care Med. 2008;36(5):1404–1411. PMID: 18434909 https://doi.org/10.1097/CCM.0b013e31816f7cf7

11. Sheu JJ, Tsai TH, Lee FY, Fang H-Y, Sun C-K, Leu S, et al. Early extracorporeal membrane oxygenator-assisted primary percutaneous coronary intervention improved 30-day clinical outcomes in patients with ST-segment elevation myocardial infarction complicated with profound cardiogenic shock. Crit Care Med. 2010;38(9):1810–1817. PMID: 20543669 https://doi.org/10.1097/CCM.0b013e3181e8acf7

12. Huang CC, Hsu JC, Wu YW, Ke S-R, Huang J-H, Chiu K-M, Liao PC. Implementation of extracorporeal membrane oxygenation before primary percutaneous coronary intervention may improve the survival of patients with ST-segment elevation myocardial infarction and refractory cardiogenic shock. Int J Cardiol. 2018;269:45–50. PMID: 30077527 https://doi.org/10.1016/j.ijcard.2018.07.023

13. Choi KH, Yang JH, Hong D, Park TK, Lee JM, Song YB, et al. Optimal timing of venoarterial-extracorporeal membrane oxygenation in acute myocardial infarction patients suffering from refractory cardiogenic shock. Circ J. 2020;84(9):1502–1510. PMID: 32684541 https://doi.org/10.1253/circj.CJ-20-0259

14. Kosmopoulos M, Bartos JA, Kalra R, Goslar T, Carlson C, Shaffer A, et al. Patients treated with venoarterial extracorporeal membrane oxygenation have different baseline risk and outcomes dependent on indication and route of cannulation. Hellenic J Cardiol. 2021;62(1):38– 45. PMID: 32387591 https://doi.org/10.1016/j.hjc.2020.04.013

15. Lee HH, Kim HC, Ahn CM, Lee SJ, Hong SJ, Yang JH, et al. Association Between Timing of Extracorporeal Membrane Oxygenation and Clinical Outcomes in Refractory Cardiogenic Shock. JACC Cardiovasc Interv. 2021;14(10):1109–1119. PMID: 34016408 https://doi.org/10.1016/j.jcin.2021.03.048

16. Rajsic S, Treml B, Jadzic D, Breitkopf R, Oberleitner C, Popovic Krneta M, Bukumiric Z. Extracorporeal membrane oxygenation for cardiogenic shock: a meta-analysis of mortality and complications. Ann Intensive Care. 2022;12(1):93. PMID: 36195759 https://doi.org/10.1186/s13613022-01067-9