PMID- 33099278 OWN - NLM STAT- MEDLINE DCOM- 20210514 LR - 20210924 IS - 1522-9645 (Electronic) IS - 0195-668X (Linking) VI - 41 IP - 38 DP - 2020 Oct 7 TI - Prevention and treatment of pulmonary congestion in patients undergoing venoarterial extracorporeal membrane oxygenation for cardiogenic shock. PG - 3753-3761 LID - 10.1093/eurheartj/ehaa547 [doi] AB - Cardiogenic shock is still a major driver of mortality on intensive care units and complicates approximately 10% of acute coronary syndromes with contemporary mortality rates up to 50%. In the meantime, percutaneous circulatory support devices, in particular venoarterial extracorporeal membrane oxygenation (VA-ECMO), have emerged as an established salvage intervention for patients in cardiogenic shock. Venoarterial extracorporeal membrane oxygenation provides temporary circulatory support until other treatments are effective and enables recovery or serves as a bridge to ventricular assist devices, heart transplantation, or decision-making. In this critical care perspective, we provide a concise overview of VA-ECMO utilization in cardiogenic shock, considering rationale, critical care management, as well as weaning aspects. We supplement previous literature by focusing on therapeutic issues related to the vicious circle of retrograde aortic VA-ECMO flow, increased left ventricular (LV) afterload, insufficient LV unloading, and severe pulmonary congestion limiting prognosis in a relevant proportion of patients receiving VA-ECMO treatment. We will outline different modifications in percutaneous mechanical circulatory support to meet this challenge. Besides a strategy of running ECMO at lowest possible flow rates, novel therapeutic options including the combination of VA-ECMO with percutaneous microaxial pumps or implementation of a venoarteriovenous-ECMO configuration based on an additional venous cannula supplying towards pulmonary circulation are most promising among LV unloading and venting strategies. The latter may even combine the advantages of venovenous and venoarterial ECMO therapy, providing potent respiratory and circulatory support at the same time. However, whether VA-ECMO can reduce mortality has to be evaluated in the urgently needed, ongoing prospective randomized studies EURO-SHOCK (NCT03813134), ANCHOR (NCT04184635), and ECLS-SHOCK (NCT03637205). These studies will provide the opportunity to investigate indication, mode, and effect of LV unloading in dedicated sub-analyses. In future, the Heart Teams should aim at conducting a dedicated randomized trial comparing VA-ECMO support with vs. without LV unloading strategies in patients with cardiogenic shock. CI - Published on behalf of the European Society of Cardiology. All rights reserved. (c) The Author(s) 2020. For permissions, please email: journals.permissions@oup.com. FAU - Lusebrink, Enzo AU - Lusebrink E AD - Intensive Care Unit, Medizinische Klinik und Poliklinik I, Klinikum der Universitat Munchen, Marchioninistrasse 15, 81377 Munich, Germany. AD - DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance, Medizinische Klinik und Poliklinik I, Klinikum der Universitat Munchen, Marchioninistrasse 15, 81377 Munich, Germany. FAU - Orban, Mathias AU - Orban M AD - Intensive Care Unit, Medizinische Klinik und Poliklinik I, Klinikum der Universitat Munchen, Marchioninistrasse 15, 81377 Munich, Germany. AD - DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance, Medizinische Klinik und Poliklinik I, Klinikum der Universitat Munchen, Marchioninistrasse 15, 81377 Munich, Germany. FAU - Kupka, Danny AU - Kupka D AD - Intensive Care Unit, Medizinische Klinik und Poliklinik I, Klinikum der Universitat Munchen, Marchioninistrasse 15, 81377 Munich, Germany. AD - DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance, Medizinische Klinik und Poliklinik I, Klinikum der Universitat Munchen, Marchioninistrasse 15, 81377 Munich, Germany. FAU - Scherer, Clemens AU - Scherer C AD - Intensive Care Unit, Medizinische Klinik und Poliklinik I, Klinikum der Universitat Munchen, Marchioninistrasse 15, 81377 Munich, Germany. AD - DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance, Medizinische Klinik und Poliklinik I, Klinikum der Universitat Munchen, Marchioninistrasse 15, 81377 Munich, Germany. FAU - Hagl, Christian AU - Hagl C AD - Herzchirurgische Klinik und Poliklinik, Klinikum der Universitat Munchen, Marchioninistrasse 15, 81377 Munich, Germany. FAU - Zimmer, Sebastian AU - Zimmer S AD - Medizinische Klinik und Poliklinik II, Universitatsklinikum Bonn, Sigmund-Freud-Strasse 25, 53127 Bonn, Germany. FAU - Luedike, Peter AU - Luedike P AD - Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center, University Hospital Essen, Hufelandstrasse 55, 45122 Essen, Germany. FAU - Thiele, Holger AU - Thiele H AD - Heart Center Leipzig at University of Leipzig, Department of Internal Medicine/Cardiology, Leipzig Heart Institute, Strumpellstrasse 39, 04289 Leipzig, Germany. FAU - Westermann, Dirk AU - Westermann D AD - Klinik fur Allgemeine und Interventionelle Kardiologie, Universitatsklinikum Hamburg-Eppendorf, Martinistrasse 52, 20251 Hamburg, Germany. FAU - Massberg, Steffen AU - Massberg S AD - Intensive Care Unit, Medizinische Klinik und Poliklinik I, Klinikum der Universitat Munchen, Marchioninistrasse 15, 81377 Munich, Germany. AD - DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance, Medizinische Klinik und Poliklinik I, Klinikum der Universitat Munchen, Marchioninistrasse 15, 81377 Munich, Germany. FAU - Schafer, Andreas AU - Schafer A AD - Klinik fur Kardiologie und Angiologie, Medizinische Hochschule Hannover, Carl-Neuberg-Strasse 1, 30625 Hannover, Germany. FAU - Orban, Martin AU - Orban M AD - Intensive Care Unit, Medizinische Klinik und Poliklinik I, Klinikum der Universitat Munchen, Marchioninistrasse 15, 81377 Munich, Germany. AD - DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance, Medizinische Klinik und Poliklinik I, Klinikum der Universitat Munchen, Marchioninistrasse 15, 81377 Munich, Germany. LA - eng PT - Journal Article PL - England TA - Eur Heart J JT - European heart journal JID - 8006263 SB - IM CIN - Eur Heart J. 2021 Jun 21;42(24):2397-2398. PMID: 33393993 CIN - Eur Heart J. 2021 Jun 21;42(24):2399-2400. PMID: 33394031 CIN - Eur Heart J. 2021 Aug 21;42(32):3103-3104. PMID: 33675638 CIN - Eur Heart J. 2021 Aug 21;42(32):3105-3106. PMID: 33675639 MH - *Extracorporeal Membrane Oxygenation MH - *Heart-Assist Devices MH - Humans MH - Prospective Studies MH - Pulmonary Circulation MH - Shock, Cardiogenic/therapy OTO - NOTNLM OT - Cardiogenic shock OT - Extracorporeal life support (ECLS) OT - Percutaneous microaxial pump OT - Venoarterial extracorporeal membrane oxygenation (ECMO) EDAT- 2020/10/26 06:00 MHDA- 2021/05/15 06:00 CRDT- 2020/10/25 00:11 PHST- 2020/02/09 00:00 [received] PHST- 2020/04/07 00:00 [revised] PHST- 2020/06/15 00:00 [accepted] PHST- 2020/10/25 00:11 [entrez] PHST- 2020/10/26 06:00 [pubmed] PHST- 2021/05/15 06:00 [medline] AID - 5938603 [pii] AID - 10.1093/eurheartj/ehaa547 [doi] PST - ppublish SO - Eur Heart J. 2020 Oct 7;41(38):3753-3761. doi: 10.1093/eurheartj/ehaa547.