How to organise ECMO programmes for cardiac failure in adults
Despite advances with Extracorporeal membrane oxygenation (ECMO) and emerging evidence guiding the use of this therapy, there remains a need for additional evidence to guide best practices in critically ill patients with cardiac failure and cardiac arrest [1,2]. Venoarterial ECMO is one of several short-term, or temporary mechanical circulatory support (MCS) options, i.e., catheter- or cannula-based vascular access with mechanical pumps that are used for first-line rescue therapy in patients with refractory cardiogenic shock [3,4]. This recently published position paper, written by a multidisciplinary team of experts highlights key aspects of care delivery, with the goal of codifying the current use of this rapidly growing technology .
Firstly, rigorous patient selection and careful attention to potential complications should be key factors in guiding decision-making and optimising patient outcomes [6,7]. But for some indications, there are not enough data to create definitive criteria. This is particularly relevant for units that operate programmes, which perform both Extracorporeal Cardiopulmonary Resuscitation (ECPR) as well as ECMO for cardiogenic shock, where decisions often have to be made with limited clinical information. The recent development of prognostic scoring systems, such as the Survival After Venoarterial ECMO (SAVE) score, may help guide clinicians in selecting appropriate candidates for ECMO [7,8].
The authors recommend that ECMO for cardiac failure should ideally be performed at experienced, high-volume centres with a minimum of 30 cases per year and with advanced cardiac capabilities, including percutaneous coronary interventions (PCI) and long-term heart replacement therapy [9,10]. ECPR may also take place in the pre-hospital setting, which is a venue under active investigation [11,12], therefore such centres should have multidisciplinary teams available 24 h a day, 7 days a week, and should ideally be equiped with mobile ECMO teams capable of cannulation and retrieval of patients from other facilities with limited ECMO ability.
Further recommendations suggest that ECMO centres should adhere to best practices and routinely perform quality assurance assessments to ensure they are meeting acceptable clinical standards. Participation in national or international databases provides a standard against which programmes can benchmark their performance. Given the relative lack of high-level evidence for ECMO in cardiac failure, ECMO centres are encouraged to participate in large, multicentre registries, such as with the Extracorporeal Life Support Organisation (ELSO), as well as research consortia, such as the International ECMO Network (ECMONet), whose missions are to better study and elucidate the role of ECMO, including in cardiac failure and cardiac arrest in adults.
Finally, each ECMO centre should ensure appropriate short and long-term follow-up for patients who survive having received ECMO, with specialty-specific consultation as needed, particularly for those with ongoing heart failure and those at risk for delayed mortality.
In conclusion, ECMO for cardiac failure is a high-risk and complex therapy. ECMO will very likely continue to play a vital role in the management of cardiovascular failure, and it should be performed responsibly within a given centre or within a network of centres, by clinicians with appropriate expertise. More precisely defining the role of ECMO in cardiac failure, and the optimal techniques that should be utilised, will require further evidence.
Article review submitted by NEXT and EJRC Member Temistocle Taccheri, Department of Anaesthesiology and Intensive Care Medicine, A. Gemelli School of Medicine University of Sacred Heart Rome.
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