ELSO Interim Guidelines for Venoarterial Extracorporeal Membrane Oxygenation in Adult Cardiac Patients (2021)

Over the past decade, the use of extracorporeal membrane oxygenation (ECMO) has increased exponentially, from approximately 30–40 patients per year in the United States 20 years ago, to over 2,000 per year currently, and rising.1 The increased utilization of ECMO has resulted from improved cannulation techniques, including percutaneous approach, as well as advances in the technology of the pumps, oxygenators, and cannulas. Despite these features, however, choosing appropriate candidates and managing their daily care can be extremely challenging. What follows is an in-depth discussion of the indications for venoarterial (VA) ECMO in adult patients affected by cardiac disease, the manner of its application, the physiology underlying the care for these patients, and the assessment and treatment of complications, including ethical and organizational issues. More in-depth material and information are provided in the Extracorporeal Life Support Organization (ELSO) 5th Edition Red Book.2 Furthermore, the recent ELSO indications about ECLS and cannulation nomenclature will be followed in this guideline.3,4 Decision Making in Adult VA ECMO for Acute Cardiac Failure VA ECMO may support patients for days or weeks as a “bridge-to-decision” that includes weaning after recovery of cardiac function, transplantation, long-term mechanical circulatory support (MCS), and withdrawal in the case of futility. Dedicated documents for the use of VA ECMO in the setting of cardiac arrest and postcardiotomy in adult patients are addressed by additional ELSO guidelines and as joint society position paper (expert consensus of EACTS/ELSO/STS/AATS).5 Indications Specific physiologic goals, monitoring, and patient selection. Cardiogenic shock suitable for ECMO is generally characterized by systemic systolic pressure less than 90, urine output < 30 ml/hour, lactate over 2, SVO2 less than 60%, altered conscious state for 6 hours unresponsive to optimal treatment (Table 1). The goal is to maintain systemic oxygen delivery at least 3 times oxygen consumption (the DO2:VO2 ratio is >3) (normal is 5, shock is 2): O2 delivery is arterial oxygen content (normal 20 ml/dl) times cardiac output (normal 30 dl/m2/min). In VA ECMO access, addressing the goal is easy because the cardiac output is the ECMO flow and the arterial hemoglobin saturation is 100%, so content is easily calculated, knowing the hemoglobin concentration (normal 15 g/dl). In VA ECMO, the drainage blood saturation (the SVO2) measures the DO2:VO2 ratio, and SVO2 is measured continuously. If the arterial saturation is 100% and the venous sat is 80%, the ratio is 5:1. So, adjusting flow and hemoglobin to maintain SVO2 over 66% assures that the goal of DO2/VO2 > 3 is met. Additional details are described in the Red Book chapter on physiology.2 Table 1. - Clinical Features of Cardiogenic Shock and Defined Contemporary Trials and Guidelines Clinical Trial/Guidelines Cardiogenic Shock Criteria SHOCK Trial (1999) • SBP < 90 mm Hg or vasopressor support to maintain SBP >90 mm Hg• Evidence of end-organ damage (UO < 30 ml/h or cool extremities)• Hemodynamic criteria: CI < 2.2 and PCWP > 15 mm Hg IABP-SOAP II (2012) • MAP < 70 mm Hg or SBP < 100 mm Hg despite adequate fluid resuscitation (at least 1 L of crystalloid or 500 ml of colloids)• Evidence of end-organ damage (AMS, mottled skin, UO < 0.5 ml/kg/h for 1 h or serum lactate >2 mmol/L) EHS-PCI (2012) • SBP < 90 mm Hg for 30 min or inotropes use to maintain SBP >90 mm Hg• Evidence of end-organ damage and increased filling pressure ESC-HF Guidelines (2016) • SBP < 90 mm Hg with appropriate fluid resuscitation with clinical and laboratory evidence of end-organ damage• Clinical: cold extremities, oliguria, AMS, narrow pulse pressure. Laboratory: metabolic acidosis, elevated serum lactate, elevated serum creatinine KAMIR-NIH (2018) • SBP < 90 mm Hg for >30 min or supportive intervention to maintain SBP >90 mm Hg• Evidence of end-organ damage (AMS, UO < 30 ml/h, or cool extremities) AMS, altered mental status; CI, cardiac index; EHS-PCI, Euro-Heart Survey Percutaneous Coronary Intervention Registry; ESC-HF, European Society of Cardiology—Heart Failure; IABP-SOAP II, Intra-aortic balloon pump in cardiogenic shock II; KAMIR-NIH, Korean Acute Myocardial Infarction Registry—National Institute of Health; MAP, mean arterial pressure; PCWP, pulmonary capillary wedge pressure; SBP, systolic blood pressure; SHOCK, Should We Emergently Revascularize Occluded Coronaries for Cardiogenic Shock; UO, Urine output. Short-term MCS should be considered in patients with refractory cardiogenic shock with a potentially reversible or surgically correctable cause.6 Compared with other percutaneous temporary MCS, VA ECMO has advantages for patients with severe biventricular failure or in case of malignant arrhythmia as well as associated pulmonary failure. The classical scenario where VA ECMO should be considered occurs when medical treatment, including fluids, inotropes, and, potentially, intra-aortic balloon pump (IABP), fails. Ideally, VA ECMO should be initiated before multiorgan failure and after thorough echocardiography evaluation. The patient’s age, comorbidities, and prognosis of the underlying illness should also be factored into the ECMO decision making. Age per se’, however, should not be considered an absolute contraindication, especially when greater prospects of cardiac recovery exist, given that the suitability for bridging durable MCS and heart transplantation may diminish with advancing age. Common situations for ECMO are patients with medical (acute myocardial infarction, fulminant myocarditis, intoxication with cardiotoxic drugs, end-stage dilated or ischemic cardiomyopathy, hypothermia with refractory cardiocirculatory instability, and massive pulmonary embolism), and postsurgical (including posttransplantation) acute cardiogenic shock. Other emerging indications for VA ECMO are shown in Figure 1.Figure 1.: Common (dark gray) and emerging situations (light gray) for venoarterial extracorporeal life support in the context of cardiogenic shock. AMI, acute myocardial infarction; APE, massive pulmonary embolism; LVAD, left ventricular assist device; Sepsis, sepsis-associated cardiomyopathy.Contraindications Regarding the contraindications for VA ECMO implant, these are listed below: - • Cardiac recovery unlikely and no indication for heart transplant or durable left ventricular (LV) assists device • Poor life expectancy (end-stage peripheral-organ diseases, malignant tumor, massive pulmonary embolisms in cancer patients, chemotherapy-induced chronic cardiomyopathy, etc.) • Severe aortic valve regurgitation • Severe vascular disease with extensive aortic and peripheral vessel involvement (calcification, stenosis, and closure), including axillary arteries • Acute Type A or B aortic dissection with extensive aortic branches (ascending, supra-aortic and femoral) involvement (preoperatively) • Severe neurologic impairment (i.e., prolonged anoxic brain damage, extensive trauma and • Severe disease with blood and • B and In the to the VA ECMO patient to of and to the patient selection. The after VA ECMO (Table is a on the assessment from the ELSO The after VA ECMO is the for ECLS use in cardiogenic shock not to postcardiotomy Other ECMO in cardiogenic including or VA ECMO and described in Table Table - The Acute cardiogenic shock or 3 heart or transplantation 3 heart disease Other to cardiogenic shock VA ECMO Age 3 1 Acute or of before of ECMO pressure 3 cardiac arrest blood pressure before ECMO mm 3 pressure before ECMO mm before ECMO to to of to II to to 30 is at failure as or of serum or as well as and is as acute creatinine with or disease is as damage or for 6 h ECMO ECMO, extracorporeal membrane Extracorporeal ventricular ventricular Table - for Extracorporeal Life the VA ECMO Cardiogenic serum lactate cardiogenic age, left disease, serum Cardiogenic shock age, neurologic myocardial or blood lactate acute systolic AMI, acute myocardial infarction; index; creatinine left VA ECMO, venoarterial extracorporeal membrane VA ECMO should be considered for cardiogenic shock 6 hours of its refractory to and fluid and in patients with reversible cardiocirculatory or for cardiocirculatory for ventricular assist or appropriate ECMO should be considered to per se’, should not be as an absolute may be to information decision before Poor life severe disease, acute brain vascular disease, and for ECMO and and information ECMO and are also in other ELSO position and in the ELSO Red VA ECMO cannulation is the for and the and the and their A arterial is adequate to flow on the patient’s or may be in clinical as when flow is arterial be associated with increased vascular complications, including vascular the and the of is to the arterial and venous in to vascular and to If the venous should be in the as is a to the and peripheral VA ECLS cannulation the of the venous and arterial and from VA venoarterial extracorporeal life vascular as a is can be in for in the should be in the and We in the the and the and arteries to the of the and of the into the vessel and In the as a can vascular is at a of the vessel and are for the in of the of the and the of the and and the the vascular of the as to the and the vascular of the the to the and the position of the arterial and the of of adequate a is in the and a of are to In as and peripheral vascular disease, a may be for The are into their and or is to the of the and of the arterial and venous drainage and is to appropriate position after position of the in the and the of the drainage at the of Cardiac echocardiography in the position in the or axillary cannulation can be as a of peripheral may be in patients with peripheral vascular disease or so as to vascular cannulation at the including vascular or and Furthermore, this can patient in the case of a VA ECMO and to In this a or the use of a to the axillary may be with to with is the vascular as a of ECLS flow with no to as can in the case of a with a as in this The cannulation of the may be or with a for to the cannulation can be for arterial access, the increased of acute brain the of when or a are not peripheral to the cannulation is should be or into the If the is should with a in the the arterial the and into the of the in the by or may be and of flow by and of the is 15 and arterial may not be with decision by saturation by should be 60%, and should be less than a the In however, is with a 6 and may be associated with vascular trauma and The of the is with a to the of the arterial the or the arteries be also considered not or to of flow adequate at least 100 is that be at the of ECMO in A of VA ECMO is the for and to the in and associated may be especially for the left and may aortic valve to acute pulmonary or of the cardiac or the aortic the for in VA ECMO should be and by the scenario Criteria to be for the assessment of aortic per venous pressure; intra-aortic balloon left left PCWP, wedge pressure; oxygen on a pulse pressure less than mm and a aortic valve with on should techniques, including a of ECMO flow end-organ to peripheral arterial increased to pulmonary arterial flow and cardiac drainage the ECMO or support to maintain to managing In myocardial recovery and should be addressed when (Table Table - and to or Extracorporeal Life Support Type of ECMO flow device device - ventricular the ventricular the valve Additional venous ECLS ECMO, extracorporeal membrane pressure; intra-aortic balloon for and the temporary percutaneous flow assist device or or cannulation and Intra-aortic balloon pump with inotropes may assist in as to support this are The of on weaning and that an of cardiac support with VA ECMO adequate and to appropriate and in the of severe peripheral vascular disease at the cannulation is in the postcardiotomy recent that in this to a peripheral cannulation is use of the for and for is The of to the is after aortic can be also as a to are advantages and when to peripheral cannulation (Table however, peripheral cannulation to and should be considered to a approach, in postcardiotomy Table - and of in Extracorporeal cannulation of flow drainage Cardiac support to ECMO flow the More with of More for of aortic valve of oxygenation cannulation flow suitable for support cardiac ECMO flow to cannulation or after for for cannulation of peripheral vessel and appropriate cannulation the of than flow suitable for prolonged patient cardiac ECMO flow of of prolonged support of of peripheral vessel and appropriate cannulation than ECMO flow flow less than cardiac of vascular ECMO, extracorporeal membrane left ventricular assist cannulation may be associated with improved and in of severe vascular disease, or axillary cannulation should be is at the of cannulation may be considered in postcardiotomy and when with severe peripheral vascular should be addressed when is as is associated with increased weaning and to be can be or with MCS or with percutaneous or and considered when the cannulation for MCS the underlying of cardiac and of the of pulmonary and of the of the and of of arterial and of the of and of as durable or patients with cardiac failure and pulmonary function, are for MCS on ECLS (Table Table - ECMO for Support in Cardiac Failure ECLS VA ECMO • for potentially reversible cardiogenic shock of VA ECMO • Failure to from where recovery for patients with cardiogenic shock where arterial VA ECMO axillary • cardiogenic shock where not cardiogenic shock with vascular aortic dissection • support where recovery is in weeks • support where recovery is in weeks • support where recovery is in weeks extracorporeal life left left LVAD, left ventricular assist device; pulmonary ventricular assist device; VA ECMO, venoarterial extracorporeal membrane its less with peripheral VA ECMO, with to or is a for patients with acute cardiac failure refractory to The of peripheral VA ECMO the use of ECMO to by to a temporary or a of biventricular with The extracorporeal membrane oxygenation can be as a biventricular assist device with support provided by the in the with from LVAD, left ventricular assist device; that a to left an in the may biventricular support and a pump with the to ventricular support when not this and cannulation of the left left and or is for of the cardiac recovery or for of a long-term mechanical assist for temporary including a to an support described this a left is potentially the for in the of cardiac recovery as a to or heart peripheral venoarterial ECMO to the use of ECMO as a temporary ventricular assist device with the of venoarterial ECMO ventricular cannulation and of drainage ventricular recovery and of temporary left ventricular cannulation to ECMO, extracorporeal membrane support can be provided with an ECMO in case of the of associated support or an percutaneous venous to the and to the pulmonary a is described for temporary support of the with of a long-term is to other of severe the can be and In the of the cannulation of the may be cannulation or a a percutaneous the is the cannulation may be with a or In patients with cardiac and pulmonary can myocardial recovery occurs and may be by to ECMO myocardial recovery is or with the use of ECMO, of blood to arterial and venous of the the of the blood in the by the axillary or cannulation has also described in this the drainage to the of the or may blood from the to the may also to A in this setting includes use of the ECMO as a temporary with an in the The device can be in (Table to support the left or and the can be from the when pulmonary or can support patients for a of to and the of and is to patients with acute in myocardial recovery is prolonged support may be Table - ECLS for Cardiac and Support ECMO VA ECMO • for potentially reversible cardiogenic shock of VA ECMO axillary • cardiogenic shock where not cardiogenic shock with vascular cardiogenic shock with long-term support with patient VA ECMO • Failure to from where recovery for patients with cardiogenic shock where arterial for severe cardiac and failure ECMO • circulatory on for severe cardiac and failure ECMO • to • to • to with to and to • Severe on VA Severe cardiac and failure where recovery is before recovery to or long-term support may be extracorporeal life left left LVAD, left ventricular assist device; pulmonary ventricular assist device; VA ECMO, venoarterial extracorporeal membrane ECMO should be so as to or biventricular failure. Poor pulmonary with to to aortic oxygenation may ECMO improved cardiac to or in the case of use of cannulation with a or The daily care for patients on VA ECMO is and of care and that from the the extracorporeal and the (Table and Figure Table - Clinical Extracorporeal arterial blood pressure • of ECMO blood flow • of oxygenation in aortic of oxygenation • of oxygenation in aortic of oxygenation • elevated filling pressure • Support indication for • cardiac output as indication of pulmonary flow pulmonary flow can be by • cardiac and of contraindications to VA ECMO • of vascular and cannulation • of ECMO support • assessment of and cardiac • Cardiac assessment weaning • • of and and brain extracorporeal life left VA ECMO, venoarterial extracorporeal membrane Figure to and managing the VA ECLS to use ELSO Red Book 5th VA venoarterial extracorporeal life and to to appropriate is the of VA ECMO venous saturation information oxygen and so to arterial blood pressure is in VA ECMO as the pulse pressure the of cardiac when in with an assessment of aortic valve and the pulse pressure may and The as well as pulse should be for blood as well as oxygenation to capillary may adequate pulse in may arterial blood to adequate A pulmonary or should be considered VA ECMO, as of elevated filling may the use of to in VA cardiac output VA ECMO is may an indication of pulmonary flow and in the can be by The of venous pressure as well as venous and venous oxygen should be with these may on the cannulation and and the of the extracorporeal and the and A of VA ECMO and is echocardiography and vascular indications from cardiac and of contraindications to VA ECMO, to of vascular and of the cannulation optimal of extracorporeal support and assessment of and cardiac to a weaning from VA ECMO to In this is to that the to be with the of the VA ECMO and its on patients should and on VA ECMO mechanical and, on the VA ECMO are a including of with a and and of with pressure are A may also to elevated may in the pulmonary and pulmonary The can also be or by pulmonary blood flow or pulmonary in VA ECMO, or a daily fluid the associated with in VA pulmonary is a in VA ECMO, should be by or as may on and long-term on ECMO should be considered to the of mechanical and and with and of and VA ECMO are in Table Table - Clinical Extracorporeal • with • pulmonary and pulse pressure mm Hg and aortic valve ECMO flow inotropes, or as and to and • • care • and • • and treatment of including vessel and • altered • for a fluid • device to ECMO ECMO, extracorporeal membrane left pressure. Specific of of VA ECMO are and with is a of VA ECMO as in in a ELSO and in recent and treatment of should be as a as The use of and to is with peripheral and on VA ECMO, should be that and of can be altered VA ECMO and illness and may and especially for patients with or Regarding and and be in the VA ECMO patients on ECMO for shock may brain before patients should as as after ECMO is to neurologic If is care with the of cardiac If is evidence of brain damage, care should for neurologic If is no neurologic ECMO for should be of VA ECMO, is that prognosis is by the and of the underlying disease and multiorgan the and is of to bridging to long-term MCS or In care of VA ECMO includes the of mechanical to fluid and and as in Table and Figure Table - of Extracorporeal and of use of for cannulation of use of of and after VA ECMO pulse of of and after VA of after of MAP to a of inotropes, and for of pulmonary of when oxygenation of and saturation on of the brain and cannulation membrane after in ECMO flow and to and mm after the by of or pressure and or in case of or of or of blood left MAP, mean arterial pressure; MAP, mean arterial pressure; pulmonary VA ECMO, venoarterial extracorporeal membrane care should venous adequate oxygen delivery of including and to oxygenation pressure to cardiac blood and The use of a pulmonary to to acute brain of and as as support is prolonged of ECMO VA ECMO is an and are and potentially life and treatment are patient to will and Table - of of Extracorporeal ELSO to > Cardiac or or or 30 of with massive and are not with the use of are to cannulation should be by with and the use of a will the of from to may be an increased for in the the and the to Percutaneous with may and when to an of percutaneous over cannulation has not shown and in this are Furthermore, as the of of is use of or for and is are and may in than of the Specific to the ECMO A of ECMO is the especially in the can to failure acute the pump in and massive to ECMO is after prolonged resuscitation should in a ECMO ECMO of of for of and with the of are in VA ECMO in a of the or of a clinical Specific to VA ECMO is that VA ECMO however, the is the in blood pressure to the flow in to a and, aortic valve or VA ECMO flow should be at the adequate and however, with increased myocardial pulmonary and in the left cardiac at ECMO on the a when the is by of the blood when the and is severe damage to the heart and brain can to blood and saturation be from the If of not the an additional to the may and can easily will the of the and with are to on and to be by of arterial blood after of ECMO including of and is for percutaneous In the of is should be in of ECMO flow and at the arterial or venous cannulation may and after ECMO The of a to the should be considered in the of oxygenation and refractory and should be at ECMO should be also to and VA ECMO VA ECMO weaning should be considered when patients cardiac the for support to maintain an adequate pulse pressure mm Hg mean arterial pressure of mm and sat at of VA ECMO should be of pump flow and weaning weaning is and to biventricular function, of as well as is a of cardiac output. be in this to and cardiac output with the VA ECMO VA ECMO flow is by 500 ml are after of no support or at of 1 of ECMO flow to of the and heart may not be when of the ECMO or is Trial is a weaning that can be The arterial flow is and 1 L of flow is to the and venous In with the this for assessment of weaning is the are MAP > mm > systolic mm and on of inotropes or inotropes and are as a weaning should to that are associated with ECMO are to from VA ECMO support days be considered for temporary support to for recovery as as systolic is with systolic before VA ECMO be considered for or heart for should be on the Society for and guidelines is of neurologic multiorgan age, or cancer as contraindications to durable support and heart transplantation and to these is with of care in patients are not candidates for is to with a and withdrawal of involvement of care should be considered in patients with VA ECMO to assist with of the of and for ECMO and decision for venoarterial extracorporeal membrane oxygenation and in patients with cardiogenic shock. CI, cardiac index; venous pressure; LVAD, left ventricular assist device; left ventricular MAP, mean arterial blood pressure; VA venoarterial extracorporeal life VA ECMO weaning should be considered when patients in the of ECLS including MAP > mm > systolic mm and on Trial or a the arterial and venous assessment with or ELSO support ECMO a of that ethical by of its to as a for The ECMO the to and the use of ECMO in a that not life also the ethical its use to the patient and or the and The and the The of is generally because the situations in ECMO is are that the for after its The be of this and of ECMO support and of appropriate care should in situations where ECMO is unlikely to be of or supportive care or may be of in these and support to are for decision The ECMO the ECMO can as a of in about the utilization of ECMO for of and by a can of the of the to and of ECMO should be The Society In ECLS is not a to or the with the of the of ECMO to support patients is in clinical the evidence to support its use is to this is the of its in and the on to with the of of ECMO has to be and in clinical the of ECMO, decision should the of myocardial and, the of bridging to durable MCS or of the should a discussion of the the of bridging to and be a of support should recovery not in with the patient’s ECMO in the care of these patients should be in on this of a with should be for to and be of the ECMO We and the ELSO for in the