Haemodynamic implications of VA‐ECMO vs. VA‐ECMO plus Impella CP for cardiogenic shock in a large animal model

Abstract

Abstract Aims Veno‐arterial extracorporeal membrane oxygenation (VA‐ECMO) with profound left ventricular (LV) failure is associated with inadequate LV emptying. To unload the LV, VA‐ECMO can be combined with Impella CP (ECMELLA). We hypothesized that ECMELLA improves cardiac energetics compared with VA‐ECMO in a porcine model of cardiogenic shock (CS). Methods and results Land‐race pigs (weight 70 kg) were instrumented, including a LV conductance catheter and a carotid artery Doppler flow probe. CS was induced with embolization in the left main coronary artery. CS was defined as reduction of ≥50% in cardiac output or mixed oxygen saturation (SvO2) or a SvO2 < 30%. At CS VA‐ECMO was initiated and embolization was continued until arterial pulse pressure was <10 mmHg. At this point, Impella CP was placed in the ECMELLA arm. Support was maintained for 4 h. CS was induced in 15 pigs (VA‐ECMO n = 7, ECMELLA n = 8). At time of CS MAP was <45 mmHg in both groups, with no difference at 4 h (VA‐ECMO 64 mmHg ± 11 vs. ECMELLA 55 mmHg ± 21, P = 0.08). Carotid blood flow and arterial lactate increased from CS and was similar in VA‐ECMO and ECMELLA [239 mL/min ± 97 vs. 213 mL/min ± 133 (P = 0.6) and 5.2 ± 3.3 vs. 4.2 ± 2.9 mmol/ (P = 0.5)]. Pressure‐volume area (PVA) was significantly higher with VA‐ECMO compared with ECMELLA (9567 ± 1733 vs. 6921 ± 5036 mmHg × mL/min × 10−3, P = 0.014). Total diureses was found to be lower in VA‐ECMO compared with ECMELLA [248 mL (179–930) vs. 506 mL (418–2190); P = 0.005]. Conclusions In a porcine model of CS, we found lower PVA, with the ECMELLA configuration compared with VA‐ECMO, indicating better cardiac energetics without compromising systemic perfusion.

Keywords

• Cardiogenic shock
• VA‐ECMO
• Impella
• ECMELLA
• Pressure‐volume loops