Impressively increasing availability of mechanical circulatory/cardiac support systems (MCSs) worldwide, together with the deepening of the knowledge of critical care medical practitioners, has inevitably led to the discussion about further improvements of intensive care associated to MCS. An appealing topic of the left ventricle (LV) overload related to VA ECMO support endangering myocardial recovery is being widely discussed within the scientific community. Unloading of LV leads to the reduction in LV end-diastolic pressure, reduction in pressure in the left atrium, and decrease in the LV thrombus formation risk. Consequently, better conditions for myocardial recovery, with comfortable filling pressures and a better oxygen delivery/demand ratio, are achieved. The combination of VA ECMO and Impella device, also called ECPELLA, seems to be a promising strategy that may bring the improvement of CS mortality rates. The series of presented trials and meta-analyses clearly showed the potential benefits of this strategy. However, the ongoing research has brought a series of new questions, such as whether Impella itself is the only appropriate unloading modality, or any other approach to unload LV would be beneficial in the same way. Benefits and potential risks of LV unloading and its timing are being discussed in this current review.

2nd Department of Medicine Department of Cardiovascular Medicine 1st Faculty of Medicine Charles University Prague and General University Hospital Prague 12808 Prague Czech Republic

Department of Anaesthesiology and Intensive Care Medicine 1st Faculty of Medicine Charles University Prague and General University Hospital Prague 12808 Prague Czech Republic

Emergency Service of Central Bohemia 27201 Kladno Czech Republic

Zobrazit více v PubMed

ECMO Registry of the Extracorporeal Life Support Organization (ELSO), Ann Arbor, Michigan, June 2023. [(accessed on 17 September 2023)]. Available online: https://www.elso.org/registry.aspx.

Ostadal P., Rokyta R., Karasek J., Kruger A., Vondrakova D., Janotka M., Naar J., Smalcova J., Hubatova M., Hromadka M., et al. Extracorporeal Membrane Oxygenation in the Therapy of Cardiogenic Shock: Results of the ECMO-CS Randomized Clinical Trial. Circulation. 2023;147:454–464. doi: 10.1161/CIRCULATIONAHA.122.062949. PubMed DOI

Thiele H., Zeymer U., Akin I., Behnes M., Rassaf T., Mahabadi A.A., Lehmann R., Eitel I., Graf T., Seidler T., et al. Extracorporeal Life Support in Infarct-Related Cardiogenic Shock. N. Engl. J. Med. 2023 doi: 10.1056/NEJMoa2307227. PubMed DOI

Zeymer U., Freund A., Hochadel M., Ostadal P., Belohlavek J., Rokyta R., Massberg S., Brunner S., Lüsebrink E., Flather M., et al. Venoarterial extracorporeal membrane oxygenation in patients with infarct-related cardiogenic shock: An individual patient data meta-analysis of randomised trials. Lancet. 2023 doi: 10.1016/S0140-6736(23)01607-0. PubMed DOI

Hill J.D., O’Brien T.G., Murray J.J., Dontigny L., Bramson M.L., Osborn J.J., Gerbode F. Prolonged Extracorporeal Oxygenation for Acute Post-Traumatic Respiratory Failure (Shock-Lung Syndrome) N. Engl. J. Med. 1972;286:629–634. doi: 10.1056/NEJM197203232861204. PubMed DOI

Stretch R., Sauer C.M., Yuh D.D., Bonde P. National Trends in the Utilization of Short-Term Mechanical Circulatory Support: Incidence, Outcomes, and Cost Analysis. J. Am. Coll. Cardiol. 2014;64:1407–1415. doi: 10.1016/j.jacc.2014.07.958. PubMed DOI

Cavarocchi N.C. Introduction to Extracorporeal Membrane Oxygenation. Crit. Care Clin. 2017;33:763–766. doi: 10.1016/j.ccc.2017.06.001. PubMed DOI

Rao P., Khalpey Z., Smith R., Burkhoff D., Kociol R.D., Mehmood M., Alhussein M., Moayedi Y., Posada J.D., Ross H., et al. Venoarterial Extracorporeal Membrane Oxygenation for Cardiogenic Shock and Cardiac Arrest. Circ. Heart Fail. 2018;11:e004905. doi: 10.1161/CIRCHEARTFAILURE.118.004905. PubMed DOI

de Waha S., Fuernau G., Eitel I., Desch S., Thiele H. Long-term prognosis after extracorporeal life support in refractory cardiogenic shock—Results from a real-world cohort. EuroIntervention. 2016;12:414. doi: 10.4244/EIJV12I3A71. PubMed DOI

Pavasini R., Cirillo C., Campo G., Nobre Menezes M., Biscaglia S., Tonet E., Ferrari R., Patel B.V., Price S. Extracorporeal Circulatory Support in Acute Coronary Syndromes: A Systematic Review and Meta-Analysis. Crit. Care Med. 2017;45:e1173–e1183. doi: 10.1097/CCM.0000000000002692. PubMed DOI

Atti V., Narayanan M.A., Patel B., Balla S., Siddique A., Lundgren S., Velagapudi P. A Comprehensive Review of Mechanical Circulatory Support Devices. Heart Int. 2022;16:37–48. doi: 10.17925/HI.2022.16.1.37. PubMed DOI PMC

El Sibai R., Bachir R., El Sayed M. ECMO use and mortality in adult patients with cardiogenic shock: A retrospective observational study in U.S. hospitals. BMC Emerg. Med. 2018;18:20. doi: 10.1186/s12873-018-0171-8. PubMed DOI PMC

Belohlavek J., Hunziker P., Donker D.W. Left ventricular unloading and the role of ECpella. Eur. Heart J. Suppl. 2021;23:A27–A34. doi: 10.1093/eurheartj/suab006. PubMed DOI PMC

Burkhoff D., Sayer G., Doshi D., Uriel N. Hemodynamics of Mechanical Circulatory Support. J. Am. Coll. Cardiol. 2015;66:2663–2674. doi: 10.1016/j.jacc.2015.10.017. PubMed DOI

Rupprecht L., Lunz D., Philipp A., Lubnow M., Schmid C. Pitfalls in percutaneous ECMO cannulation. Heart Lung Vessel. 2015;7:320–326. PubMed PMC

Meani P., Gelsomino S., Natour E., Johnson D.M., La Rocca H.-P.B., Pappalardo F., Bidar E., Makhoul M., Raffa G., Heuts S., et al. Modalities and Effects of Left Ventricle Unloading on Extracorporeal Life support: A Review of the Current Literature. Eur. J. Heart Fail. 2017;19:84–91. doi: 10.1002/ejhf.850. PubMed DOI

Hogue C.W., Levine A., Hudson A., Lewis C. Clinical Applications of Near-infrared Spectroscopy Monitoring in Cardiovascular Surgery. Anesthesiology. 2021;134:784–791. doi: 10.1097/ALN.0000000000003700. PubMed DOI PMC

Al-Fares A.A., Randhawa V.K., Englesakis M., McDonald M.A., Nagpal A.D., Estep J.D., Soltesz E.G., Fan E. Optimal Strategy and Timing of Left Ventricular Venting During Veno-Arterial Extracorporeal Life Support for Adults in Cardiogenic Shock: A Systematic Review and Meta-Analysis. Circ. Heart Fail. 2019;12:e006486. doi: 10.1161/CIRCHEARTFAILURE.119.006486. PubMed DOI

Glazier J.J., Kaki A. The Impella Device: Historical Background, Clinical Applications and Future Directions. Int. J. Angiol. 2019;28:118–123. doi: 10.1055/s-0038-1676369. PubMed DOI PMC

Meani P., Lorusso R., Pappalardo F. ECPella: Concept, Physiology and Clinical Applications. J. Cardiothorac. Vasc. Anesth. 2022;36:557–566. doi: 10.1053/j.jvca.2021.01.056. PubMed DOI

Giunta M., Recchia E.G., Capuano P., Toscano A., Attisani M., Rinaldi M., Brazzi L. Management of harlequin syndrome under ECPELLA support: A report of two cases and a proposed approach. Ann. Card. Anaesth. 2023;26:97–101. PubMed PMC

Pappalardo F., Schulte C., Pieri M., Schrage B., Contri R., Soeffker G., Greco T., Lembo R., Müllerleile K., Colombo A., et al. Concomitant implantation of Impella® on top of veno-arterial extracorporeal membrane oxygenation may improve survival of patients with cardiogenic shock. Eur. J. Heart Fail. 2017;19:404–412. doi: 10.1002/ejhf.668. PubMed DOI

Grajeda Silvestri E.R., Pino J.E., Donath E., Torres P., Chait R., Ghumman W. Impella to unload the left ventricle in patients undergoing venoarterial extracorporeal membrane oxygenation for cardiogenic shock: A systematic review and meta-analysis. J. Card. Surg. 2020;35:1237–1242. doi: 10.1111/jocs.14560. PubMed DOI

Fiorelli F., Panoulas V. Impella as unloading strategy during VA-ECMO: Systematic review and meta-analysis. Rev. Cardiovasc. Med. 2021;22:1503–1511. doi: 10.31083/j.rcm2204154. PubMed DOI

Grandin E.W., Nunez J.I., Willar B., Kennedy K., Rycus P., Tonna J.E., Kapur N.K., Shaefi S., Garan A.R. Mechanical Left Ventricular Unloading in Patients Undergoing Venoarterial Extracorporeal Membrane Oxygenation. J. Am. Coll. Cardiol. 2022;79:1239–1250. doi: 10.1016/j.jacc.2022.01.032. PubMed DOI PMC

Russo J.J., Aleksova N., Pitcher I., Couture E., Parlow S., Faraz M., Visintini S., Simard T., Di Santo P., Mathew R., et al. Left Ventricular Unloading During Extracorporeal Membrane Oxygenation in Patients With Cardiogenic Shock. J. Am. Coll. Cardiol. 2019;73:654–662. doi: 10.1016/j.jacc.2018.10.085. PubMed DOI

Schrage B., Becher P.M., Bernhardt A., Bezerra H., Blankenberg S., Brunner S., Colson P., Cudemus Deseda G., Dabboura S., Eckner D., et al. Left Ventricular Unloading Is Associated With Lower Mortality in Patients With Cardiogenic Shock Treated With Venoarterial Extracorporeal Membrane Oxygenation: Results From an International, Multicenter Cohort Study. Circulation. 2020;142:2095–2106. doi: 10.1161/CIRCULATIONAHA.120.048792. PubMed DOI PMC

Schrage B., Sundermeyer J., Blankenberg S., Colson P., Eckner D., Eden M., Eitel I., Frank D., Frey N., Graf T., et al. Timing of Active Left Ventricular Unloading in Patients on Venoarterial Extracorporeal Membrane Oxygenation Therapy. JAC Heart Fail. 2023;11:321–330. doi: 10.1016/j.jchf.2022.11.005. PubMed DOI