Venoarterial Extracorporeal Membrane Oxygenation as a Bridge to Recovery or Bridge to Heart Replacement Therapy in Refractory Cardiogenic Shock.

PURPOSE OF THE REVIEW: The purpose of this review is to describe the outcomes following refractory cardiogenic shock (CS) requiring mechanical circulatory support and factors associated with successful and unsuccessful weaning from VA-ECMO. Based on the presented data, we will propose a weaning and bridging algorithm with the aim of facilitating this complex process.

RECENT FINDINGS: Refractory CS requiring VA-ECMO support is associated with high early mortality. Approximately 1/3 of the patients weaned from ECMO do not survive until hospital discharge. When evaluating the ability to wean from ECMO etiology of CS, hemodynamics, end-organ function, pulmonary blood oxygenation, metabolic status, and echocardiographic assessments must be considered. When cardiopulmonary function is not recoverable, heart replacement therapies (HRT) should be considered early as patients may have better outcomes. Durable weaning from VA-ECMO is obtainable in well-selected patients. Patients should be separated from the ECMO circuit in the presence of myocardial recovery, hemodynamic stability, and restored end-organ function. If myocardial recovery is unsatisfactory (severe LV dysfunction), HRT should be considered early in suitable candidates. Future research is needed to identify predictors of sustained myocardial recovery.