ECMO, Escalation Therapy, AMI Cardiogenic Shock

Interview with Dr. Benedikt Schrage: ECMELLA in Cardiogenic Shock


Benedikt Schrage, MD, discusses his paper, “From Escalation to Weaning Strategies—How to Integrate the ECMELLA Concept.”  This is one of eight articles published in the European Heart Journal supplement, “From Patient Selection to Escalation Strategies: Mechanical Circulatory Support in Cardiogenic Shock.”

Dr. Schrage explains the rationale behind the ECMELLA approach, which combines mechanical circulatory support (MCS) with an Impella® device with veno-arterial extracorporeal membrane oxygenation (VA ECMO); he describes why it is relevant in the treatment of patients with cardiogenic shock. Clinicians primarily rely on peripheral (femoral) cannulation for VA ECMO in patients with cardiogenic shock. This configuration creates retrograde blood flow to the aorta, increasing afterload. Increased LV afterload has been shown to reduce the likelihood of myocardial recovery and lead to severe complications, such as pulmonary edema and LV thrombus. Impella pumps blood from the left ventricle into the aorta, which can offset the increase in LV afterload. 

Typical patients for ECMELLA support are those in cardiogenic shock following a large acute myocardial infarction or those with pre-existing heart failure. Dr. Schrage emphasizes data showing that this approach is best when implemented early rather than as a bailout strategy.
Dr. Schrage describes clinical scenarios of escalation and de-escalation in patients with cardiogenic shock and a “protected weaning approach” in which the patient can be weaned from VA ECMO with increased Impella support. He also discusses scenarios in which an Impella CP®  device is used in the ECMELLA approach and scenarios in which patients can benefit from more support and the ability to ambulate with an axillary-inserted Impella 5.5® as a means of de-escalation from ECMELLA.

Dr. Schrage explains that many patients who are candidates for ECMELLA support are also eventually candidates for a durable left ventricular assist device (LVAD). He highlights how the Impella 5.5 pump can “roadtest” the heart prior to implantation of a durable LVAD.

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