ECMO and pMCS for Advanced Cardiogenic Shock

Prof. Dr. Evgenij V. Potapov discusses tailored solutions for treating advanced cardiogenic shock by combining ECLS, or ECMO, with percutaneous mechanical circulatory support (pMCS), a combination known in Europe as ECMELLA. He gave this presentation at the European Association for Cardio-Thoracic Surgery (EACTS) 2022 annual meeting in Milan, Italy. 

Dr. Potapov opens by highlighting that mechanical circulatory support is now a class IIa recommendation in the ESC guidelines for management of patients with cardiogenic shock. He shows which MCS devices are used at which SCAI stages of cardiogenic shock and explains why patients who have undergone CPR and patients with lactate levels higher than 7.8 mmol/L require more than Impella 5.5® with SmartAssist®. These patients, he explains, require ECLS, which provides advantages such as bedside percutaneous implantation, circulatory support up to 10 L/min, and blood oxygenation and decarboxylation. Yet ECLS is associated with complications, notably lung edema because the heart is not unloaded, and the need to wean patients within 5-10 days. Thus, the need for ECMELLA: ECLS + Impella®.

Dr. Potapov explains how he uses single arterial access for ECMELLA at his institution with a case video demonstrating the technique. He emphasizes that this technique provides maximal cardiopulmonary support through single arterial access, a balance of unloading and RV support, mobilization, and the ability to de-escalate and explant ECLS at bedside after a few days followed by full support of the LV.

He describes the results seen in patients between May 2020 and September 2022 and the algorithm at his institution for temporary MCS device selection in cardiogenic shock. He shows how survival is increased by following the algorithm and how the number of patients they’ve supported with Impella has increased. Now up to 50% of patients at the German Heart Center in Berlin are supported with Impella before they receive durable LVAD.

Dr. Potapov concludes that axillary implanted Impella-based temporary MCS is the first choice for patients with severe cardiogenic shock and that an algorithm-based approach for escalation and de-escalation improves survival in patients with severe cardiogenic shock.