Veno-arterial extracorporeal membrane oxygenation in addition to primary PCI in patients presenting with ST-elevation myocardial infarction
Neth Heart J
Veno-arterial extracorporeal membrane oxygenation in addition to primary PCI in patients presenting with ST-elevation myocardial infarction
F. S. van den Brink 0 1 2 3
A. D. Magan 0 1 2 3
P. G. Noordzij 0 1 2 3
C. Zivelonghi 0 1 2 3
P. Agostoni 0 1 2 3
F. D. Eefting 0 1 2 3
J. M. ten Berg 0 1 2 3
M. J. Suttorp 0 1 2 3
B. R. Rensing 0 1 2 3
J. P. van Kuijk 0 1 2 3
P. Klein 0 1 2 3
E. Scholten 0 1 2 3
J. A. S. van der Heyden 0 1 2 3
0 Department of Intensive Care, St Antonius Hospital , Nieuwegein , The Netherlands
1 Department of Cardiology, St Antonius Hospital , Nieuwegein , The Netherlands
2 F. S. van den Brink
3 Department of Cardio-Thoracic Surgery, St Antonius Hospital , Nieuwegein , The Netherlands
Introduction Primary percutaneous coronary intervention (pPCI) in ST-elevation myocardial infarction (STEMI) can cause great haemodynamic instability. Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) can provide haemodynamic support in patients with STEMI but data on outcome and complications are scarce. Methods An in-hospital registry was conducted enrolling all patients receiving VA-ECMO. Patients were analysed for medical history, mortality, neurological outcome, complications and coronary artery disease. Results Between 2011 and 2016, 12 patients underwent pPCI for STEMI and received VA-ECMO for haemodynamic support. The majority of the patients were male (10/12) with a median age of 63 (47-75) years and 4 of the 12 patients had a history of coronary artery disease. A cardiac arrest was witnessed in 11 patients. The left coronary artery was compromised in 8 patients and 4 had right coronary artery disease. All patients were in Killip class IV. Survival to discharge was 67% (8/12), 1-year survival was 42% (5/12), 2 patients have not yet reached the 1-year survival point but are still alive and 1 patient died within a year after discharge. All-cause mortality was 42% (5/12) of which mortality on ECMO was 33% (4/12). Patient-related complications occurred in 6 of the 12 patients: 1 patient suffered major neurological impairment, 2 patients suffered haemorrhage at the cannula site, 2 patients had limb ischaemia and 1 patient had a haemorrhage elsewhere. There were no VA-ECMO hardware malfunctions. Conclusion VA-ECMO in pPCI for STEMI has a high survival rate and neurological outcome is good, even when the patient is admitted with a cardiac arrest.
ECMO; STEMI; Cardiogenic Shock; Circulatory Support
Primary percutaneous coronary intervention (pPCI) is the
cornerstone in the treatment of ST-elevation myocardial
infarction (STEMI). STEMI can cause great haemodynamic
instability through a mechanism of cardiac failure and
subsequent low output state [1–7]. Haemodynamic support
following STEMI is quintessential for survival and
preservation of cardiac function . Historically, this consisted of
medical support with inotropes and vasopressors, and
mechanical circulatory support by an intra-aortic balloon pump
[1, 3, 8, 9]. Recently more advanced devices have been
introduced such as the Impella device, but data on its safety
and efficacy are inconclusive [10, 11].
Another form of haemodynamic support is veno-arterial
extracorporeal membrane oxygenation (VA-ECMO) [12,
13]. VA-ECMO can provide haemodynamic support in
patients with STEMI with cardiac failure and possible
concomitant respiratory failure due to pulmonary congestion
[13–15]. Its mechanism is based on the combined
possibility of circulatory support through laminar flow of blood
in the aorta and simultaneous oxygenation of the patient’s
blood. Blood flow of up to 7 litres/min can be generated in
Data on outcome and complications in the use of
VAECMO in pPCI for STEMI are scarce but first reports on
this therapy show promising results [6, 14–16]. This study
was performed to gain insight into the outcome and
complications of the use of VA-ECMO in pPCI for STEMI with
subsequent haemodynamic instability.
An in-hospital registry was kept at the St Antonius
Hospital, Nieuwegein, the Netherlands involving all patients
who received treatment with VA-ECMO for haemodynamic
support from 2009 onwards. Data were collected
retrospectively and included those patients who received VA-ECMO
in addition to pPCI for STEMI. All patients were analysed
at baseline for age, sex, medical history, previous
coronary artery disease, coronary artery occlusion in STEMI,
concomitant coronary artery disease, SYNTAX score,
concomitant chronic total occlusion, Survival After VA-ECMO
(SAVE) score, procedural characteristics including mode of
cannulation and concomitant use of other circulatory
support (e. g. intra-aortic balloon pump (IABP)), left
ventricular function prior to admission, survival, complications
related to the patient (e. g. bleeding at the cannula site, limb
ischaemia), complications related to the ECMO hardware
(e. g. pump failure, clot formation), length of ECMO
treatment and length of stay on the ICU and in hospital,
haemodynamic parameters, mortality and neurological outcome
Shock was defined according to the Killip class . The
SYNTAX score was calculated using the online SYNTAX
score calculator (http://www.syntaxscore.com/calculator/
start.htm) . The SAVE score, an Extracorporeal Life
Support Organisation (ELSO) endorsed and validated score,
was calculated to compare predicted mortality with actual
morality . This was done by using the online SAVE
score calculator (http://www.save-score.com/).
Neurological outcome was defined using the Cerebral Performance
Categories Scale (CPC) where a CPC score of 1 and 2 was
deemed a good neurological outcome .
VA-ECMO using the Maquet Cardiohelp, which is a
system using an integrated rotational pump and oxygenator,
was introduced at the St Antonius Hospital in Nieuwegein,
the Netherlands, a large referral centre, in 2009. From
2009 until 2016 a total of 118 patients received VA-ECMO
for circulatory support for various conditions such as post
cardiotomy, pulmonary embolism and septic shock.
Between 2009 and 2016 a total of 19,116 patients underwent
coronary intervention of which 3,673 underwent a PCI for
an acute ischaemic event; 12 patients underwent pPCI for
STEMI and received additional VA-ECMO treatment for
haemodynamic support. The first VA-ECMO in addition to
STEMI was performed in 2011.
The majority of patients were male (83%, 10/12) with a
median age of 63 (47–75) years with only 1 patient over the
age of 70 years. A history of coronary artery disease in
the form of a previous PCI was present in 33% (4/12) of
the patients of whom 1 patient had recently diagnosed left
main disease. None of the patients had undergone previous
cardiac surgery and none had known left ventricular
impairment prior to admission. None of the patients had a
history of neurological events in the form of either a transient
ischaemic attack or a cerebrovascular accident. Only 1
patient had known pulmonary disease in the form of chronic
obstructive pulmonary disease GOLD class 1/4. Two
patients had a history of diabetes mellitus type 2 and 42%
(5/10) were known to have a history of hypertension. There
was 1 patient with a history of peripheral artery disease in
the form of implantation of an aortic bifurcation
prosthesis 11 years prior to primary pPCI for STEMI. All patients
were in cardiogenic shock, Killip class 4 prior to and after
pPCI (Table 1).
The indication for VA-ECMO was determined by the
attending interventional cardiologist and intensivist. An
outof-hospital cardiac arrest (OHCA) prior to presentation was
witnessed in 9 of the 12 patients. Two patients suffered an
in-hospital cardiac arrest. The left coronary artery was
involved in 67% (8/12) of the patients: 3 left main coronary
arteries, 5 left anterior descending arteries and the other
4 patients had right coronary artery disease. The mean
SYNTAX score was 23.7 (
). A total of 8 patients
had concomitant coronary artery disease, 3 of which had
a chronic total occlusion of another coronary artery than the
culprit lesion. Culprit lesion revascularisation was achieved
in 92% (11/12). One patient had an unsuccessful
evacuation of thrombus in the right coronary artery. One patient
had successful revascularisation of the culprit lesion but
received a coronary artery bypass graft (CABG) after pPCI.
Mean systolic blood pressure was 70 (53–80) mm Hg
upon admission while mean pH was 7.2 (6.97–7.40) and
mean lactate was 6.4 (1.6–12.0) mmol/l. Mean blood
bicarbonate levels were 16.5 (5.7–22.2) mmol/l and mean
creatinine was 134 (72–333) mmol/l.
All patients were cannulated at the Cathlab. The cannula
was inserted in the femoral artery in 9 of the 12 patients. In
3 patients the cannula was placed in the subclavian artery
by the attending cardiothoracic surgeon. The venous
cannula was placed in the femoral vein in all but 1 patient,
where it was placed in the internal jugular vein. Two
patients had an IABP in situ at the time of cannulation. The
mean SAVE score was –5.5 (–2––11) which represents an
estimated survival of 30% (25–35%) (Table 2).
Initially the patients were weaned off the device
according to the clinical judgement of the attending physician.
However, after 2015 the patients were weaned off the device
using the local weaning protocol, which is a modification
of an existing protocol .
Survival to discharge was 67% (8/12), 1-year survival was
42% (5/12), and 2 of the 12 patients have not yet reached
the 1-year survival point but are still alive. Mortality on
VA-ECMO was 33% (4/12) and this was also the 30-day
mortality. All patients who survived VA-ECMO survived to
discharge. All-cause mortality was 42% (5/12); in the
aforementioned 33% (4/12) of patients who died on VA-ECMO
and 1 patient who died within a year after discharge due to
aspiration pneumonia, this was caused by poor neurological
status after prolonged cardiopulmonary resuscitation.
Both the patients who received IABP and ECMO
survived to discharge. The patient who suffered unsuccessful
evacuation of the thrombus in the right coronary artery did
not survive. The patient who underwent subsequent CABG
did survive to discharge.
Patient-related complications occurred in 6 of the 12
patients: 2 patients suffered haemorrhage at the cannula site
and 1 patient had a haemorrhage elsewhere in the form
of a venous haemorrhage of the liver due to the venous
cannula position while on VA-ECMO. Limb ischaemia
occurred in 3 of the 12 patients; in 1 of these patients the
right leg was eventually amputated due to clot formation
between the ECMO cannula and antegrade leg perfusion.
One patient suffered major neurological impairment;
however, this was not due to intracranial haemorrhage but due
to prolonged resuscitation prior to receiving the VA-ECMO
treatment. There were no malfunctions regarding the
VAECMO hardware. The median time spent on VA-ECMO
was 5 (
) days, the median time spent on the ICU was
) days and the median time spent in hospital was
) days (Table 3).
Follow-up after VA-ECMO in pPCI for STEMI
Of the 12 patients who received VA-ECMO in pPCI for
STEMI, 1 patient received a CABG for concomitant
coronary artery disease. Another patient underwent implantation
of a left ventricular assist device (LVAD) in a designated
LVAD centre. Both of these patients survived to discharge
and are neurologically well.
This study shows that VA-ECMO is feasible in selected
patients. It could potentially improve survival in patients
undergoing primary PCI for STEMI with cardiogenic shock.
As all patients were in cardiogenic shock, VA-ECMO could
be considered a last resort therapy. There are no randomised
trials on VA-ECMO in pPCI in STEMI; observational
studies proving the concept of circulatory support with
VAECMO in pPCI in STEMI are crucial in facilitating future
research in this field [13–16]. In this observational study
VA-ECMO was feasible, safe and with a relatively low
complication rate in a very high-risk group of patients with
great haemodynamic instability. As our research shows, the
applicability of this possibly life-saving technique in
patients undergoing pPCI for STEMI could be the start of
a future randomised controlled trial, which may prove its
use in pPCI in STEMI.
Although the SAVE score is not a substitute for clinical
assessment of patients, the difference between the predicted
mortality and the actual mortality may illustrate that
VAECMO is especially useful in the treatment of cardiogenic
shock caused by STEMI.
Only 1 patient suffered a poor neurological outcome due
to prolonged resuscitation prior to pPCI and VA-ECMO
cannulation. This illustrates the safety of using VA-ECMO
in haemodynamic support with respect to possible
neurological injury. Three patients suffered limb ischaemia. This
is a known complication of VA-ECMO due to occlusion of
the femoral artery distal of the cannula and the cannula
itself. The correct use of antegrade leg perfusion via insertion
of an extra small diameter cannula can prevent this (known
as leg-ECMO or L-ECMO). However, 1 patient had
adequate leg perfusion but developed clot formation between
the retrograde ECMO cannula and antegrade leg perfusion.
Surgical exploration during decannulation could prevent
this. Studies in this regard are lacking and a standardised
procedure of decannulation might prevent this
complication. No intracranial haemorrhages were reported, although
patients on VA-ECMO received dual antiplatelet therapy
and heparin infusion for the ECMO circuit. This indicates
the safety of the described procedure from a neurological
point of view.
One of the possible drawbacks of VA-ECMO in pPCI for
STEMI is the increase in afterload of the heart. This is a
direct result of competitive flow of the ECMO circuit with the
cardiac circulation . However, as one of the major
problems of cardiogenic shock is poor organ perfusion with
subsequent organ failure, adequate organ perfusion is pivotal
in improving patient survival and may outweigh the
problem of increased afterload. In our study increased afterload
did not lead to a worsening of the outcome for patients. If
increasing afterload poses a problem in the treatment of
patients on VA-ECMO, the use of an IABP or Impella device
for left ventricular unloading may be considered. However,
the possible benefit of left ventricular unloading is purely
theoretical and not yet proven in a clinical setting.
Furthermore, the use of an IABP or Impella or other left ventricular
unloading device may increase the risk of possible
complications, the complexity of the procedure as well as the cost
of treatment. In this study, 2 patients received concomitant
IABP therapy during VA-ECMO treatment and survived to
discharge. This illustrates the technical feasibility of these
two combined techniques.
Two of the described patients underwent VA-ECMO
treatment in pPCI for STEMI and received additional
therapy after pPCI in the form of a CABG and LVAD
placement. This underlines the possibility of using
VAECMO as a bridge to LVAD, treatment or recovery.
In this study, all patients were placed on VA-ECMO
after PCI. In future studies patients could be placed
on VA-ECMO prior to PCI. The first strategy has the
benefit of earlier revascularisation, but it prolongs poor
organ perfusion and haemodynamic shock. The second
strategy may delay revascularisation by several minutes
but allows early haemodynamic support and stabilisation
as VA-ECMO therapy can be administered directly in the
Cathlab. Future research must establish the ideal timing of
The absence of ECMO-related hardware failure is a
possible indication of the reliability of the Maquet Cardiohelp.
It can be safely used in this group of patients.
Our study has several limitations. It is an observational
study comprising only a small number of patients. As
patients were selected for VA-ECMO by the attending
physicians, selection bias is present. Furthermore, there was no
control group; future studies may be able to randomise
patients undergoing pPCI for STEMI with subsequent
cardiogenic shock to VA-ECMO treatment versus medical
treatment. The small number of patients in this study makes any
sound statistical conclusion impossible. In future registries
with larger numbers of patients, this can be overcome.
In our group, VA-ECMO in pPCI for STEMI had a
survival to discharge rate of 67% and even when patients were
admitted with an OHCA this outcome was favourable. The
complication rate was relatively low and neurological
outcome was good. Further research is needed to identify the
patients most likely to benefit from VA-ECMO treatment in
pPCI for STEMI. Randomised controlled trials are needed
to prove the efficacy of this new and promising technique.
Conflict of interest F.S. van den Brink, A.D. Magan, P.G. Noordzij,
C. Zivelonghi, P. Agostoni, F.D. Eefting, J.M. ten Berg, M.J. Suttorp,
B.R. Rensing, J.P. van Kuijk, P. Klein and E. Scholten, J.A.S van der
Heyden declare that they have no competing interests.
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