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Open Access 23-01-2024 | ECMO | Original Paper

Discussion of hemodynamic optimization strategies and the canonical understanding of hemodynamics during biventricular mechanical support in cardiogenic shock: does the flow balance make the difference?

Authors: Nikolaos Patsalis, Julian Kreutz, Giorgos Chatzis, Carlo-Federico Fichera, Styliani Syntila, Maryana Choukeir, Sebastian Griewing, Bernhard Schieffer, Birgit Markus

Published in: Clinical Research in Cardiology | Issue 4/2024

Abstract

Background

Mechanical circulatory support (MCS) devices may stabilize patients with severe cardiogenic shock (CS) following myocardial infarction (MI). However, the canonical understanding of hemodynamics related to the determination of the native cardiac output (CO) does not explain or support the understanding of combined left and right MCS. To ensure the most optimal therapy control, the current principles of hemodynamic measurements during biventricular support should be re-evaluated.

Methods

Here we report a protocol of hemodynamic optimization strategy during biventricular MCS (VA-ECMO and left ventricular Impella) in a case series of 10 consecutive patients with severe cardiogenic shock complicating myocardial infarction. During the protocol, the flow rates of both devices were switched in opposing directions (+ / − 0.7 l/min) for specified times. To address the limitations of existing hemodynamic measurement strategies during biventricular support, different measurement techniques (thermodilution, Fick principle, mixed venous oxygen saturation) were performed by pulmonary artery catheterization. Additionally, Doppler ultrasound was performed to determine the renal resistive index (RRI) as an indicator of renal perfusion.

Results

The comparison between condition 1 (ECMO flow > Impella flow) and condition 2 (Impella flow > VA-ECMO flow) revealed significant changes in hemodynamics. In detail, compared to condition 1, condition 2 results in a significant increase in cardiac output (3.86 ± 1.11 vs. 5.44 ± 1.13 l/min, p = 0.005) and cardiac index (2.04 ± 0.64 vs. 2.85 ± 0.69, p = 0.013), and mixed venous oxygen saturation (56.44 ± 6.97% vs. 62.02 ± 5.64% p = 0.049), whereas systemic vascular resistance decreased from 1618 ± 337 to 1086 ± 306 s*cm⁻⁵ (p = 0.002). Similarly, RRI decreased in condition 2 (0.662 ± 0.05 vs. 0.578 ± 0.06, p = 0.003).

Conclusions

To monitor and optimize MCS in CS, PA catheterization for hemodynamic measurement is applicable. Higher Impella flow is superior to higher VA-ECMO flow resulting in a more profound increase in CO with subsequent improvement of organ perfusion.

Graphical Abstract

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Title: Discussion of hemodynamic optimization strategies and the canonical understanding of hemodynamics during biventricular mechanical support in cardiogenic shock: does the flow balance make the difference?
Authors: Nikolaos Patsalis
Julian Kreutz
Giorgos Chatzis
Carlo-Federico Fichera
Styliani Syntila
Maryana Choukeir
Sebastian Griewing
Bernhard Schieffer
Birgit Markus
Publication date: 23-01-2024
Publisher: Springer Berlin Heidelberg
Keywords: ECMO
ECMO
Cardiogenic Shock
Cardiogenic Shock
Published in: Clinical Research in Cardiology / Issue 4/2024
Print ISSN: 1861-0684
Electronic ISSN: 1861-0692
DOI: https://doi.org/10.1007/s00392-024-02377-7

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Discussion of hemodynamic optimization strategies and the canonical understanding of hemodynamics during biventricular mechanical support in cardiogenic shock: does the flow balance make the difference?

Abstract

Background

Methods

Results

Conclusions

Graphical Abstract

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Abstract

Background

Methods

Results

Conclusions

Graphical Abstract

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