Temporary Mechanical Circulatory Support.

Managing Cardiogenic Shock in the Era of Multimodal Mechanical Support: Bridging to Transplant or Recovery

276 Days of Support by a Micro-Axial Left Ventricular Assist Device as a Bridge to Heart Transplant.

The Impella 5.5 is a surgically implanted micro-axial left ventricular assist device (LVAD) increasingly utilized for mechanical circulatory support (MCS) in cardiogenic shock. While typically used for acute support up to FDA-approved 14 days, reports of prolonged utilization remain limited. We present the case of a 69-year-old male who presented with severe biventricular failure and cardiogenic shock who was bridged to heart transplantation (HT) utilizing a single Impella 5.5 for a total of 276 days. His prolonged support course was managed through a multidisciplinary approach addressing recurrent ventricular arrhythmias, renal failure, heparin-induced thrombocytopenia, and device management (suction alarms and purge flow limitations). Following successful HT, the explanted device demonstrated no mechanical injury or thrombus, and pathologic examination revealed no significant device-related structural heart damage. The patient was discharged without major complications and continued to do well at 5-month follow-up.

Outcomes of Temporary Right Ventricular Assist Device at the Time of Durable Left Ventricular Assist Device Implantation.

Patients requiring a right ventricular assist device (RVAD) after durable left ventricular assist device (LVAD) surgery have historically worse outcomes than those with isolated LVADs. Preoperative mechanical circulatory support (MCS) with venoarterial extracorporeal membrane oxygenation (ECMO) or micro-axial pumps complicates right heart assessment by altering loading conditions. We examined 1 year outcomes of patients receiving temporary RVADs at the time of durable LVAD. From February 2017 to August 2025, 102 patients were reviewed. Right ventricular assist device decannulation, ventilator liberation, and intensive care unit (ICU) discharge were assessed using Fine-Gray subdistribution analysis with death as a competing risk; 1 year survival was evaluated by Kaplan-Meier analysis. Analysis included 59 planned, 28 unplanned, and 15 delayed RVADs (45 percutaneous, 57 surgical). One year survival was 64.0 ± 6.5% for planned, 50.2 ± 10.3% for unplanned, and 50.3 ± 13.6% for delayed RVAD. Percutaneous and surgical RVAD survival were 60.1 ± 7.5% and 55.1 ± 7.1%. Preoperative MCS was independently associated with improved survival (hazard ratio [HR]: 0.36, confidence interval [CI]: 0.17-0.83), with micro-axial pump showing the strongest association. Preoperative micro-axial support and planned RVAD were associated with improved 1 year survival after durable LVAD surgery; whether this reflects a causal relationship where the preconditioning of the right ventricle improves postoperative outcomes cannot be determined from this retrospective design.

Time-critical VA-ECMO-facilitated resuscitation and recovery after acute myocardial infarction with cardiogenic shock and cardiac arrest: a case report

Background Cardiogenic shock (CS) in the setting of acute myocardial infarction (AMI) remains associated with poor prognosis, with mortality of approximately 40%–50% despite mechanical circulatory support (MCS). Its prognostic value remains uncertain because AMI with CS involves complex pathophysiology requiring consideration of implantation timing, organ protection, functional recovery, and prevention of device-related and critical illness-related complications. Case summary A 36-year-old man with diabetes and hypertension was readmitted with recurrent chest pain 6 months after coronary stent implantation for acute anterior AMI. Initial electrocardiographic findings and rapid hemodynamic deterioration supported AMI complicated by CS. During emergency percutaneous coronary intervention, he developed refractory ventricular fibrillation (VF)/cardiac arrest (CA). Because the arrest occurred under in-hospital monitoring, chest compressions were initiated immediately, resulting in a no-flow interval of 0 min. A multidisciplinary extracorporeal cardiopulmonary resuscitation (ECPR) response was activated, and effective veno-arterial extracorporeal membrane oxygenation (VA-ECMO) flow was established 20 min after activation during ongoing cardiopulmonary resuscitation (CPR). This constituted ECPR rather than VA-ECMO after stable return of spontaneous circulation (ROSC), allowing right coronary artery revascularization with TIMI grade 3 flow. After VA-ECMO initiation, the early post-resuscitation course was complicated by weak arterial pulsatility, restricted aortic valve opening, persistent hyperlactatemia, pneumonia/airway infection, transient hyperosmolar disturbance, and suspected post-arrest hypoxic-ischemic encephalopathy. With multidisciplinary management, cardiac function improved, organ dysfunction partially recovered, and the patient was discharged on day 10 with a favorable neurological outcome, defined as Cerebral Performance Category (CPC) grade 1 and modified Rankin Scale (mRS) score 0. At 1 year, follow-up confirmed sustained functional recovery, patent previous stenting without significant restenosis, no progression of other coronary lesions, return to normal quality of life, and persistently favorable neurological status (CPC 1; mRS 0). Conclusion This case highlights the value of program-level ECPR readiness in selected patients with monitored AMI-related refractory CA during emergency percutaneous coronary intervention. A pre-primed ECMO pathway, immediate CPR, 0 min no-flow exposure, 20 min ECPR activation-to-flow interval, completed coronary reperfusion, and complication-focused multidisciplinary care contributed to this outcome. As a single case, these findings should be interpreted as hypothesis-generating rather than supporting unselective VA-ECMO use in AMI complicated by CS.

Hemodynamic monitoring during ECMO.

A physiology-guided, multimodal monitoring framework that integrates pressure, flow, volumetric, and microcirculatory information with serial echocardiography is proposed to guide individualized clinical decision-making and avoid delayed recognition of ventricular failure or regional hypoperfusion.

Role of ECMO and percutaneous mechanical thrombectomy in the management of acute pulmonary embolism

Interventional treatment for hemodynamically unstable pulmonary embolism (PE) is now common due to the fact that unstable PE carries a significant 30-day mortality. Unstable PE is characterized by acute right ventricular failure, hypotension, and hypoxia, leading to cardiovascular collapse and cardiac arrest. Implementation of veno-arterial extracorporeal membrane oxygenation (VA-ECMO) acutely provides oxygenation support to improve hypoxia and offload the right ventricular (RV) pressure in the belief that rapid reduction of hypoxia and right ventricular (RV) pressure will provide a window for intervention. There are two strategies for using VA-ECMO during percutaneous pulmonary mechanical thrombectomy: VA-ECMO-assisted mechanical thrombectomy and mechanical thrombectomy with standby VA-ECMO. While the application of VA-ECMO in percutaneous mechanical thrombectomy is usually short-term, providers must be cognizant that it can be associated with substantial multisystem morbidity due to a systemic inflammatory response, hemorrhagic stroke, renal dysfunction, and bleeding, and these factors will impact outcomes. The evolving paradigm positions VA-ECMO combined with percutaneous pulmonary mechanical thrombectomy as the preferred combination for the high-risk PE patients (acute right ventricular failure, refractory shock, and cardiac arrest), while percutaneous pulmonary mechanical thrombectomy alone with standby VA-ECMO suffices for most intermediate PE patients.