Dr. Susanna Price,
Extracorporeal membrane oxygenation (ECMO) in adults had little support has until recently, due to historically poor outcomes from clinical trials. Positive results from ECMO during the H1N1 pandemic, together with emerging positive data from the fields of resuscitation/emergency medicine have led to a resurgence of interest in this technique.
Pascal Vranckx provided an overview of the principles of ECMO, putting veno-arterial (VA) - ECMO in the context of other mechanical circulatory support. The importance of recognising the high risk patient prior to undertaking catheter laboratory interventions was explored, including use of the SYNTAX II score. Thus, although an immediate survival benefit may not be apparent, anticipation and early ECMO might improve longer-term outcomes. Although data from the ELSO registry for ECMO-CPR are encouraging (27% survival) the continuing lack of adequately powered studies for ECMO in advanced heart failure and cardiogenic shock was highlighted.
Bulent Gorenek discussed the use of acute resynchronisation therapy in patients with cardiogenic shock. Here, the literature remains limited to small case series/reports in predominantly inotrope-dependent patients, but with clear potential benefit. Discussion centred on the challenges of patient selection, including the importance of QRS duration.
David Newby discussed the potential risks/benefits of non-invasive ventilation (NIV) and inspiratory positive pressure ventilation (IPPV) in the context of the pathophysiological processes of heart-lung interactions.The findings of studies using non-invasive ventilation were discussed – concluding that in pulmonary oedema, whilst NIV does not save lives, it results in early resolution of physiological abnormalities and patient symptoms. In terms of IPPV in patients with cardiogenic shock, the importance of managing the haemodynamics of preload-sensitivity prior to instituting therapy was discussed.
Christian Hassager detailed different cooling strategies and their potential impact on cardiovascular physiology. Positive evidence was discussed (cardiac surgery, accidental hypothermia, organ preservation) versus negative (use in acute brain injury, cerebrovascular accident). Three main cardiovascular areas were explored; cardiac arrest (cerebral protection-the possible benefit is substantial, but evidence inadequate), acute myocardial infarction (early animal and human studies have shown potential benefit in reducing infarct size), and cardiogenic shock (animal studies and small clinical series showing potential survival benefit). Two major trials have recently been completed in these areas (CHILL-MI in STEMI patients, and TTM in cardiac arrest), with the results expected in 2013.The conclusion of all presenters highlighted the paucity of quality studies, despite the huge potential benefits of interventions, together with the challenges of research in the critically ill.
Session Title: Cardiogenic shock - multimodality device therapy
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