ECMO, Protected PCI
ECpella in Refractory Cardiac Arrest
Prof. Carsten Skurk, MD, and Tharusan Thevathasan, MD, discuss their recently published case report titled, “Case report: Refractory cardiac arrest supported with veno-arterial-venous extracorporeal membrane oxygenation and left-ventricular Impella CP® heart pump - Physiological insights and pitfalls of ECMELLA.” Prof. Skurk explains, “We intended to provide an in-depth analysis of clinical parameters and hemodynamics in a complex patient who was treated with multiple MCS devices.”
The case report describes a 50-year-old patient with refractory cardiac arrest due to ventricular fibrillation. The patient was supported with VA-ECMO in the cath lab during emergency PCI, a treatment strategy known as extracorporeal cardiopulmonary resuscitation (ECPR). After PCI, the patient experienced left ventricular (LV) distension and persistent asystole and an Impella CP® heart pump was inserted along with VA-ECMO (a combination known as ECpella) to provide hemodynamic support and LV unloading. After transfer to the ICU, the patient developed upper body hypoxemia, or Harlequin phenomenon, and VA-ECMO was escalated to VAV ECMO with continued support from Impella CP heart pump.
To explain the rationale for ECpella, Dr. Thevathasan describes the basic principles of VA ECMO therapy, which provides retrograde blood flow to the heart. He emphasizes that this retrograde flow increases cardiac afterload, thus increasing LV volume and intraventricular pressure. Increased cardiac afterload impairs myocardial perfusion, increases myocardial oxygen demand, impairs stroke work, and increases pulmonary capillary wedge pressure, which can lead to pulmonary congestion and impaired pulmonary oxygen exchange.
Dr. Thevathasan explains that they added an Impella CP heart pump in this case to provide LV unloading, providing “reduction of the wall stress of the left ventricle, reduction of the pulmonary capillary wedge pressure, and also an increase in myocardial oxygen supply and also an increase in cardiac power output.”
Dr. Thevathasan also discusses management considerations in patients supported with VA ECMO and clinical considerations for Impella CP device support. Dr. Skurk talks about the impact of timing in ECPR.
Dr. Thevathasan speaks about outcomes for cardiac arrest and the Berlin Cardiac Arrest Outpatient Center pilot project, explaining “we have created a dedicated cardiac arrest outpatient care center which is based on a collaborative network between cardiologists, neurologists, psychologists, and general practitioners.” Dr. Skurk emphasizes that their future endeavors in Berlin focus on education of practitioners (eg, ECLS fellowships for cardiologists), research in the field of LV unloading in cardiac arrest, as well as patient care.