Individualized real-time clinical decision support to monitor cardiac loading during venoarterial ECMO
© Broomé and Donker. 2016
Received: 13 November 2015
Accepted: 26 December 2015
Published: 6 January 2016
Veno-arterial extracoporeal membrane oxygenation (VA ECMO) is increasingly used for acute and refractory cardiogenic shock. Yet, in clinical practice, monitoring of cardiac loading conditions during VA ECMO can be cumbersome. To this end, we illustrate the validity and clinical applicability of a real-time cardiovascular computer simulation, which allows to integrate hemodynamics, cardiac dimensions and the corresponding degree of VA ECMO support and ventricular loading in individual patients over time.
With great interest we read the recent publication by Ostadal et al. Their experimental work underscores the clinical relevance to closely monitor left-ventricular (LV) loading conditions in cardiogenic shock supported by venoarterial extracorporeal membrane oxygenation (VA ECMO) . They report on significant negative influences on intrinsic cardiac output, left ventricular performance and stroke work as a result of increasing extracorporeal blood flow intended to maximally support the circulation in cardiogenic shock. It is increasingly recognized that LV overloading during VA ECMO may cumulate in feared complications as pulmonary edema, acute lung injury after ‘bridge–bridge’ strategies and even progression to irreversible myocardial damage, all having significant impact on outcome [2–5]. Yet, in clinical practice, it can be challenging to provide adequate systemic perfusion, while equally addressing favourable LV loading conditions. The practical difficulties to optimally tailor VA ECMO may be improved by a bedside monitoring tool that allows instantaneous integration of patient-specific data on cardiac dimensions, hemodynamics, fluid loading and pharmacotherapy with the degree of circulatory VA ECMO support.
Methods and results
Comparison of clinical and simulated hemodynamic data before (two left columns) and the first day after initiation of VA-ECMO (two right columns)
On ECMO first day
Mean arterial pressure
Right ventricular systolic pressure
Central venous pressure
Left Ventricular end‐diastolic volume
Left ventricular end‐diastolic pressure
Tricuspid regurgitation velocity
Real-time cardiovascular computer modeling allows to simulate complex patient-specific clinical scenario’s as in extracorporeal support. Our findings support the notion that VA-ECMO flow should be maintained as low as possible in order to balance the simultaneous need of circulatory support and LV unloading.
MB developed the model, performed simulations, analyzed data and contributed to drafting of the manuscript. DD collected clinical data and analyzed it in relation to simulation data and also contributed to drafting of the manuscript. Both MB and DD are clinical medical doctors working with ECMO patients. Both authors read and approved the final manuscript.
This study was supported by a Grant No. 2012-2800 from the Swedish Research Council.
MB is the founder and owner of the company Aplysia Medical AB, Stockholm, Sweden having the commercial rights of the simulation model and software used in this work.
Compliance with ethical guidelines
The present study is an analysis of animal experimental data presented in a study by Ostadal et al.  and a clinical case study. The experimental study is published in J Translational Med and approved by Czech authorities in accordance with national rules and NIH rules (NIH Publication No. 85-23, revised 1985). Written informed consent to publish anonymous history, hemodynamic and imaging data was obtained from the patient in our clinical case study, who was treated in accordance with our institutional principles without any modifications related to our research.
Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
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