Table 3 Active left ventricular venting
From: Venting during venoarterial extracorporeal membrane oxygenation
Venting mode | Authors | Year | Trial Type | Trial demograhics | VA-ECMO-Indication | Venting Technique | Timing of venting initiation | |
|---|---|---|---|---|---|---|---|---|
Schrage et al. [52] | 2020 | Multicenter, retrospective (Enrollment period 2005–2019) | n = 686, median age: 56.6 years, 77.7% male, rate of decompression using Impella in total study population: 49%, 1:1 propensity matched analysis of n = 255 undergoing ECMELLA compared to n = 255 VA-ECMO alone | AMI: 64.3%; previous cardiac arrest: 67.1% [unmatched cohort] | Impella 2.5: 22.3%; Impella CP: 67.1%; Impella 5.0: 5.5%; missing data: 5.1% [matched cohort] | Impella as first device: 56%; VA-ECMO as first device: 44%; median interval from Impella to VA-ECMO: 0.0 h [matched cohort] | ||
Tongers et al. [56] | 2020 | Singlecenter, prospective (Enrollment period 2012–2016) | n = 69, median age: 57 years, 78% male, rate of decompression using Impella in total study population: 100% | AMI: 54%; cardiomyopathy: 45%; incessant ventricular arrhythmia: 1%; out-of-hospital cardiac arrest: 33% | n = 1 recieved pulmonary artery cannulation, no information on Impella subtypes | VA-ECMO as first device: 49%; Impella before percutaneous coronary intervention: 28% | ||
Colombier et al. [58] | 2019 | Singlecenter, retrospective (Enrollment period 2011–2015) | n = 1248, median age: 54 years, 71% male, n = 587 treated with VA-ECMO and IABP, rate of decompression using Impella in total study population: 2.5% (n = 31) | AMI: 52%; DCM: 23%; myocarditis: 10%; chronic valvular cardiopathy: 6%; PCS: 3% | Impella 2.5: 29%; Impella CP: 13%; Impella 5.0: 58% | Median interval between VA-ECMO and Impella implantation: 84 h; Impella upgrade within 48 h: 22% (n = 7/31) | ||
Akanni et al. [54] | 2018 | Singlecenter, retrospective (Enrollment period 2010–2014) | n = 225, median age: 57 years, 69.33% male, rate of decompression using Impella in total study population: 12.9% (n = 29) | AMI: 25.8%; PCS: 36.44%; acute decompensated heart failure: 13.3%; primary graft failure: 11.1%; other (13.3%) | Impella 2.5: 72.4%; Impella CP: 27.6%; VA-ECMO upgraded to ECMELLA: n = 14; Impella upgraded to ECMELLA: n = 15 | Impella upgraded to ECMELLA: 51.7%; VA-ECMO upgraded to ECMELLA: 48.3%; median interval from VA-ECMO to ECMELLA upgrade: 12 h; median interval from Impella to ECMELLA upgrade: 7 h | ||
Fiedler et al. [89] | 2018 | Singlecenter, retrospective (Enrollment period 2014–2017) | n = 59, rate of decompression using Impella in total study population: 20.3% (n = 12, average age: 51.8 years, 66% male) | AMI: 50%; myocarditis: 33%; mechanical complication: 8%; catheterization complication: 8%; CPR before cannulation: 41.2% [ECMELLA group] | Impella 2.5, Impella CP | No information | ||
Schrage et al. [55] | 2018 | Singlecenter, retrospective (Enrollment period 2013–2018) | n = 106, median age: 53 years, 82.1%, rate of decompression using Impella in total study population: 100% | AMI: 59.4%; acute decompensated heart failure: 19.8%; myocarditis: 9.4%; sudden cardiac death: 8.5%; cardiac arrest before device therapy: 82% | Impella 2.5: 21.7%; Impella CP: 78.3%; upgrade from Impella CP to Impella 5.0 required for VA-ECMO weaning in n = 12 | Impella as first device: 20.8%; VA-ECMO as first device: 18.9%; simultaneous implantation: 60.3%; VA-ECMO implantation during refractory cardiac arrest: 48.1% | ||
Eliet et al. [57] | 2018 | Singlecenter, retrospective (Enrollment period 2009–2013) | n = 134, rate of decompression using Impella in total study population: 20% (median age: 44 years, 78% male) | AMI: 44%; myocarditis: 11%; chronic heart failure: 33%; other: 11% [n = 27 Impella cohort] | Impella 2.5: 52%; Impella 5.0: 48%; median Impella flow: 1.9 L/min [n = 27 Impella cohort] | Median interval between VA-ECMO and Impella implantation: 20 h [n = 27 Impella cohort] | ||
Pappalardo et al. [53] | 2016 | Two-center, retrospective (Enrollment period 2013–2015) | n = 157, median age: 53 years, 87% male, rate of decompression using Impella in total study population: 21.7%, 1:2 propensity matched analysis of n = 21 undergoing ECMELLA compared to n = 42 VA-ECMO alone | AMI; refractory VT/VF: 17%; myocarditis: 8%; post heart/lung transplantation: 2% [matched cohort] | Impella 2.5, Impella CP | Concomitant implantation of VA-ECMO and Impella: 100% | ||
Pulsatile pump device (PulseCath) | Tschöpe et al. [49] | 2020 | Case report | n = 1, 49 yo, male | Myocarditis | PulseCath iVAC2L | Impella CP implantation before VA-ECMO, substitution of Impella with iVAC2L 6 days after ECMELLA initiation | |
LV-Catheter | Bloom et al. [44] | 2019 | Case report | n = 1, 45 yo, male | AMI | Percutaneous insertion of a 7Fr pigtail catheter (Medtronic) into LV; venting flow 90 ml/min | 4 days after VA-ECMO initiation | |
Hong et al. [38] | 2016 | Singlecenter, retrospective (Enrollment period 2013–2014) | n = 7, mean age: 39.9 years, 71% male | AMI: 71%; pulmonary embolism: 14%; dilated cardiomyopathy: 14%; eCPR rate: 58% | Percutaneous insertion of a 5-6Fr pigtail catheter (PIG performa) into LV | No information | ||
Barbone et al. [51] | 2011 | Case report | n = 1, 47 yo, male | AMI | Percutaneous insertion of a 7Fr pigtail catheter (Johnson&Johnson) into LV | Simultaneous with VA-ECMO initiation | ||
Fumagalli et al. [45] | 2004 | Case report | n = 1, 34 yo, male | Unknown | Percutaneous insertion of a 17Fr pediatric pigtail catheter into LV; venting flow 300 ml/min | 24 h after VA-ECMO initiation | ||
Cheung et al. [46] | 2003 | Case report | n = 1, 15 yo, male | Congenital heart disease: 100% | Percutaneous insertion of a 11Fr Mullins transseptal sheath with side holes into the LV through an iatrogenic atrial septal defect after frustrane blade septostomy | Shortly after VA-ECMO initiation | ||
Active, left ventricle (surgical) | Trans-apical | Takeda et al. [41] | 2017 | Singlecenter, retrospective (Enrollment period 2007–2016) | n = 112, analyis of n = 22 undergoing VA-ECMO and trans-apical LV cannulation (median age: 58.0 years, 77.3% male) compared to n = 90 undergoing BiVAD insertion (median age: 52.5 years, 72.2% male) | AMI: 63.6% (VA-ECMO + Vent), 53.3% (BiVAD); acute decompensated heart failure: 31.8% (VA-ECMO + Vent), 34.4% (BiVAD); myocarditis: 4.55% (VA-ECMO + Vent), 12.2% (BiVAD); patients with recent open-heart surgery did not recieve VA-ECMO + Vent, but BiVAD | Left thoracotomy, trans-apical insertion of a 28-32Fr cannula into LV through a stab incision [VA-ECMO + Vent] | Simultaneous with VA-ECMO initiation [VA-ECMO + Vent] |
Eudailey et al. [43] | 2015 | Case report | n = 1, 61 yo, male | Perioperative cardiac arrest | Trans-diaphragmatic trans-apical insertion of a 20Fr DLP sump cannula (Medtronic) into LV through a stab incision | Shortly after VA-ECMO initiation | ||
Guirgis et al. [59] | 2009 | Case report | n = 1, 17 yo, female | Myocarditis | Subxiphoid access, trans-apical insertion of 20Fr sump cannula into LV through a stab incision | Shortly after VA-ECMO initiation | ||
Trans-pulmonary | Beyls et al. [65] | 2020 | Case report | n = 1, 21 yo, female | Rocuronium-related hypersensitivity myocarditis | Trans-pulmonary insertion of a 22Fr DLP cannula (Medtronic) into LV | Shortly after VA-ECMO initiation | |
Schmack et al. [39] | 2017 | Singlecenter, retrospective (Enrollment period 2004–2014) | n = 48, mean age: 49.7 years, 64.6% male, rate of decompression using surgical LV venting in total study population: 41.6% | AMI: 12.5%; DCM: 22.8%; myocarditis: 18.8%; valvular disease: 10.4%; ischemic cardiomyopathy: 6.3%; others: 31.3%; VA-ECMO initiation post-cardiotomy: 10% (LV vent), 46% (VA-ECMO alone) (p < 0.01) | Trans-pulmonary insertion of a heparin-coated 24Fr cannula into LV | Simultaneous with VA-ECMO initiation | ||
Keenan et al. [42] | 2016 | Case series | n = 3, median age: 54 years, 100% male | AMI: 33%; ischemic cardiomyopathy: 33%; non-ischemic cardiomyopathy: 33%; out-of-hospital cardiac arrest: 33% | Right anterior thoracotomy, trans-pulmonary insertion of a 20-26Fr cannula into LV; venting flow between 400-800 ml/min | Simultaneous with VA-ECMO initiation | ||
Weymann et al. [63] | 2014 | Singlecenter, prospective (Enrollment period 2010–2013) | n = 12, median age: 31.6 years, 83% male | AMI: 25%; myocarditis: 50%; acute cardiac decompensation: 25% | Median sternotomy, trans-pulmonary insertion of a heparin-coated 24Fr venting cannula (Medtronic) into LV | Simultaneous with VA-ECMO initiation | ||
Sandrio et al. [64] | 2014 | Singlecenter, retrospective (Enrollment period 2011–2012) | n = 8, median age: 1.15 years, 50% male | Myocarditis: 37.5%; post-cardiotomy mechanical support: 50%; DCM: 12.5% | Trans-pulmonary insertion of a 10-24Fr cannula into LV | Insertion of LV venting cannula 9 h/13.5 h after VA-ECMO initiation in first two patients, respectively, remaining 6 patients had simultaneous LV venting with VA-ECMO initiation | ||
Active, left ventricle (mixed analysis) | Impella vs. VA-ECMO ± surgical venting | Patel et al. [90] | 2019 | Singlecenter, retrospective (Enrollment period 2014–2016) | n = 66, median age: 63 years (n = 30, ECMELLA ± surgical Vent group), 55 years (n = 36, VA-ECMO group, containing n = 21 with surgical Vent), 70% (ECMELLA), 67% (VA-ECMO) male | STEMI: 50% (ECMELLA), 17% (VA-ECMO) (p = 0.007) | Impella 2.5: 6.7%; Impella CP: 80%; Impella 5.0: 13.3%, no information on surgical techniques | Implantation of Impella concomitantly or within 24 h of VA-ECMO initiation in majority of cases |
Venting mode | Mechanical support duration | Follow-up time | Hemodynamic effect of decompression | Mortality outcome | Additional outcome information | Complications/adverse events | |
|---|---|---|---|---|---|---|---|
Median duration of VA-ECMO: 5.0 days (ECMELLA group), 4.0 days (VA-ECMO alone group); median duration of Impella: 6.0 days (ECMELLA) [matched cohort] | 30 days | No information | 30-day mortality rate: 56.9% (ECMELLA), 63.5% (VA-ECMO alone) (p = 0.03); 30-day mortality rate lower with early LV unloading shortly before or at VA-ECMO initiation: HR 0.76, p = 0.03 [matched cohort] | Bridge to durable LVAD: 12.4% (ECMELLA), 6.5% (VA-ECMO alone) | Severe bleeding: 38.4% (ECMELLA), 17.9% (VA-ECMO alone) (p < 0.01); moderate bleeding: 51.0% (ECMELLA), 38.5% (VA-ECMO alone) (p = 0.01); hemolysis: 33.6% (ECMELLA), 22.4% (VA-ECMO alone) (p = 0.01); intervention because of access site-related ischemia: 21.6% (ECMELLA), 12.3% (VA-ECMO alone) (p < 0.01); laparotomy because of abdominal compartment: 9.4% (ECMELLA), 3.7% (VA-ECMO alone) (p = 0.02); renal replacement therapy: 58.5% (ECMELLA), 39.1% (VA-ECMO alone) (p < 0.01) [matched cohort] | ||
Median duration of VA-ECMO: 141 h; median duration of Impella: 117 h; median duration of ECMELLA: 94 h | 6 months | Rapid decline in catecholamine requirement and blood lactate levels after Impella addition | In-hospital survival rate: 61%; 30-day survival rate: 49%; 6-month survival rate: 40%; > 13.5 h from shock-to-first-device predicted increased mortality; active withdrawal of ICU therapy according to patients living will: 12/69 | Time of shock-to-first device: 5.5 h; cardiopulmonary status at discharge: 17.4% NYHA I, 47.8% NYHA II, 34.8% NYHA III; neuromuscular status at discharge: 73.9% CPC I, 26.1% CPC II | Major bleeding: 1%; minor bleeding: 29%; minimal bleeding: 28%; no bleeding: 42%; hemolysis: 55%; acces site complications: 6%; lower extremity ischemia or compartment syndrome: 9%; stroke: 7%; device explantation due to dysfunction: 3% | ||
Median duration of Impella: 8 days | 30 days | Multiorgan failure during VA-ECMO: 81%; resolution of multiorgan failure after Impella addition: 68% | 30-day survival rate: 53% (ECMELLA group), 56% (all n = 1248 VA-ECMO treated patients); mortality rate under ECMELLA: 26% | Weaning rate: 26% (VA-ECMO), 74% (Impella); discharge rate: 39% (12/31) | Insertion site bleeding: 26%; blood transfusion: 50%; Impella displacement: 65%; lower limb ischemia: 3%; Impella insertion site infection: 3%; stroke: 19% | ||
Median duration of VA-ECMO: 3.29 days (Impella upgraded to ECMELLA), 3.65 days (VA-ECMO upgraded to ECMELLA), 3.58 days (VA-ECMO alone) | 30 days | Decrease of systolic and diastolic PAP 24 h after Impella addition (VA-ECMO upgraded to ECMELLA, p = 0.049); no significant differences in MAP, systolic/diastolic PAP and CVP 24 h after ECMELLA upgrade compared to all VA-ECMO alone | 30-day survival rate: 48.98% (VA-ECMO alone), 42.86% (VA-ECMO upgraded to ECMELLA), 48.67% (Impella upgraded to ECMELLA) (p = 0.913) | Transition to durable LVAD: 24.49% (VA-ECMO alone), 35.71% (VA-ECMO upgraded to ECMELLA), 66.67% (Impella upgraded to ECMELLA) (p < 0.05); discharge rate: 42.35% (VA-ECMO alone), 35.71% (VA-ECMO upgraded to ECMELLA), 40.00% (Impella upgraded to ECMELLA) | Bleeding: 44.83% (ECMELLA), 40.31% (VA-ECMO alone) (p = 0.688); hemolysis: 44.83% (ECMELLA); 17.35% (VA-ECMO alone) (p = 0.002); infection 0% (ECMELLA), 13.78% (VA-ECMO alone) (p = 0.03) | ||
Average duration of ECMELLA: 5.6 days | Hospita-lisation | No information | Survival rate: 58% (7/12) | Discharge rate: 58% (7/12); bridge to recovery: 5/12; bridge to orthotopic heart transplantation: 1/12; bridge to durable LVAD: 1/12 | Bleeding: 42%; hemolysis: 58.3%; renal dysfunction requiring CVVH: 33.3%; stroke: 25%; long-lasting neurologic deficits: 0% | ||
Median duration of VA-ECMO: 6.0 days; median duration of Impella: 6.0 days | 30 days | PCWP decrased after VA-ECMO upgrade to ECMELLA in all 3 patients with available data | 30-day mortality rate: 64.2%; 30-day mortality rate higher in patients who underwent eCPR; 30-day mortality rate higher in patients not weaned from VA-ECMO (p < 0.01) | VA-ECMO weaning rate: 51.9%; weaning rate in patients who underwent eCPR: 35.3% (p < 0.01) | Bleeding requiring intervention: 24.8%; hemolysis: 47.1%; vascular complication requiring intervention: 34.3%; renal replacement therapy: 59.4%; hypoxic brain damage: 19.1%; stroke: 11.4%; abdominal compartment with the need of laparotomy: 22.9%; sepsis: 41.9% | ||
No information | No infor-mation | MAP: 66 mmHg (Impella setting P1), 79 mmHg (final Impella setting) (p < 0.0001); LVEDD: 49 mm (P1), 30 mm (final) (p < 0.0001); EtCO2: 9 mmHg (P1), 19 mmHg (final) (p < 0.0001); pulmonary VTI: 2.3 cm (P1), 5 cm (final) (p = 0.001) [n = 11 patients, from whom Impella ramp test data was available] | No information | No information | No information | ||
Median duration of VA-ECMO: 148 h (ECMELLA group), 73.5 h (VA-ECMO alone group) (p = 0.2) [matched cohort] | Hospita-lisation | No information | In-hospital mortality rate: 48% (ECMELLA), 74% (VA-ECMO alone) (p = 0.04) [matched cohort] | VA-ECMO weaning rate: 48% (ECMELLA), 28% (VA-ECMO alone) (p = 0.047); bridge to next therapy or recovery: 62% (ECMELLA), 36% (VA-ECMO alone) (p = 0.048); duration of mechanical ventilation: 163 h (ECMELLA), 48 h (VA-ECMO alone) (p = 0.04) [matched cohort] | Major bleeding: 38% (ECMELLA), 29% (VA-ECMO alone) (p = 0.6); minor bleeding: 19% (ECMELLA), 24% (VA-ECMO alone) (p = 0.8); hemolysis: 76% (ECMELLA), 33% (VA-ECMO alone) (p = 0.004); CVVH: 48% (ECMELLA), 19% (VA-ECMO alone) (p = 0.02) [matched cohort] | ||
Pulsatile pump device (PulseCath) | Duration of iVAC2L support: 5 days | 11 days | Increase in LVEF from 10 to 20%, stabilization of blood pressure | No information | Patient successfully weaned from iVAC2L | Hemolysis under ECMELLA, no complications related to iVAC2L | |
LV-Catheter | Duration of VA-ECMO: 48 days; duration of LV pigtail: 4 days | 92 days | Resolution of pulmonary edema within 24 h | Patient survived | Patient bridged to heart transplantation by durable LVAD | No procedure-related complications reported | |
Median duration of VA-ECMO: 5.8 days (survivors), 6.7 days (non-survivors) (p = 0.840) | No infor-mation | LVEDD: 59 mm (pre pigtail insertion), 50 mm (post pigtail insertion) (p = 0.044); LVEF: 18.3% (pre pigtail insertion), 38.3% (post pigtail insertion) (p = 0.094) | Mortality rate: 42% | Discharge rate: 58%; VA-ECMO weaning rate: 58% | No procedure-related complications reported | ||
Duration of VA-ECMO and LV catheter venting: 4 days | 1 year | LVEDV: 221 ml (pre VA-ECMO), 136 ml (post pigtail insertion) | Patient survived | Patient bridged to heart transplantation by durable LVAD | No procedure-related complications reported | ||
Duration of VA-ECMO: 7 days | No infor-mation | PCWP: 40 mmHg (pre pigtail insertion), 7 mmHg (post pigtail insertion); CVP: 11 mmHg (pre pigtail insertion), 3 mmHg (post pigtail insertion) | Patient survived | Patient recieved heart transplantation | No procedure-related complications reported | ||
Duration of VA-ECMO and LV catheter venting: 5 days | No infor-mation | Echocardiographic imaging showed sufficient LV decompression | Patient survived | Patient recieved heart transplantation | No procedure-related complications reported | ||
Active, left ventricle (surgical) | Trans-apical | Median duration of VA-ECMO 28.6 days [VA-ECMO + Vent] | No infor-mation | No information | 30-day mortality rate: 13.6%; 1-year mortality rate: 39% [VA-ECMO + Vent] | Weaning rate: 27%; durable LVAD implantation: 46%; heart transplantation: 4.6% [VA-ECMO + Vent] | Major bleeding: 31.8%; stroke: 18.2% [VA-ECMO + Vent] |
Duration of VA-ECMO and LV venting: 2 days | 3 months | LV decompression confirmed by live TEE imaging, decreasing vasopressor requirement over subsequent 48 h | Patient survived | Discharge on postoperative day 20, dramatic improvement of LVEF from 5–10% intraoperatively to 40–45% after VA-ECMO weaning | No procedure-related complications reported | ||
No information | No infor-mation | No information | Patient survived | Bridge to biventricular assist device on post-admission day 6 | No procedure-related complications reported | ||
Trans-pulmonary | Duration of VA-ECMO and LV venting: 10 days | No infor-mation | LVEF: 5% (pre decompression), 60% (post decompression); re-opening of aortic valve and resolution of LV blood stasis post decompression | Patient survived | Discharge from ICU 54 days after cardiac arrest | No procedure-related complications reported | |
Median duration of VA-ECMO: 7.4 days (LV vent group), 5.2 days (VA-ECMO alone group) (p = 0.055) | Mean follow-up time: 0.83 years | No relevant differences in end-organ function parameters (LV vent vs. VA-ECMO alone) | 30-day mortality rate: 45% (LV vent), 75% (VA-ECMO alone) (p = 0.034); long-term survival rate showed trend towards LV vent superiority (p = 0.066) | Bridge to VAD: 50% (LV vent), 14% (VA-ECMO alone) (p < 0.01); death during support: 25% (LV vent), 57% (VA-ECMO alone) (p = 0.027) | No information | ||
Duration of VA-ECMO and LV venting: 5 days/18 days/7 days, respectively | 20 months/18 days/7 days, re-spectively | Improvement of LVEF from 15 to 25% in one patient | Mortality rate: 66% | Surviving patient was successfully weaned from VA-ECMO after 5 days and underwent heart transplantation after 14 days | Persistent bleeding from axillary cannulation site requiring relocation in one patient, upper extremity swelling with subsequent operative revision of arterial cannula in one patient, temporary CVVH required in one patient | ||
Mean duration of VA-ECMO: 8.0 days | No infor-mation | Reduction of serum bilirubin 3 days after VA-ECMO initiation compared to pre-operative | Mortality rate: 41.7% | Discharge rate: 58.3%; surival on VA-ECMO support: 100% | Bleeding requiring surgical re-exploration: 41.7%; coagulation disorder: 66.7%; renal failure requiring hemodialysis: 50%; stroke: 8.3%; deep sternal wound infection: 8.3% | ||
Median duration of VA-ECMO: 6 days | No infor-mation | Improvement of left ventricular distension and pulmonary edema after venting initiation in first two patients, intraoperative TEE imaging showed improved LV venting with cannulation of LV instead of LA | Mortality rate: 25% | Weaning rate: 87.5%; bridge to biventricular assist device: 25% | In-line thrombus development in venous and left ventricular venting cannula resulting in deterioration and death of the patient | ||
Active, left ventricle (mixed analysis) | Impella vs. VA-ECMO ± surgical venting | Median duration of VA-ECMO: 144 h (ECMELLA), 149 h (VA-ECMO) | 30 days | Inotropic score at day 2: 0 (ECMELLA), 11 (VA-ECMO) (p = 0.001); inotropic score at day 3: 0 (ECMELLA), 4 (VA-ECMO) (p = 0.02) | 30-day mortality rate: 57% (ECMELLA), 78% (VA-ECMO) (p = 0.02); 1-year all-cause mortality rate: 69% (ECMELLA), 87% (VA-ECMO) (p = 0.02); mortality rate in patients with CPR: 75% (ECMELLA), 87% (VA-ECMO) | Weaning rate: 53% (ECMELLA), 47% (VA-ECMO) (p = 0.81); bridge to recovery: 40% (ECMELLA), 22% (VA-ECMO); bridge to durable LVAD: 33% (ECMELLA), 13% (VA-ECMO); need for mechanical support 24 h post decannulation in surviving patients: 20% (ECMELLA), 56% (VA-ECMO); three patients in ECMELLA group required re-cannulation | Major bleeding: 36% (ECMELLA), 33% (VA-ECMO); hemolysis: 22% (ECMELLA), 27% (VA-ECMO); need for dialysis: 22% (ECMELLA), 27% (VA-ECMO); stroke: 5.6% (ECMELLA), 10% (VA-ECMO) |