Left ventricular physiological effects of veno-arterial ECMO support during cardiogenic shock

项目摘要/摘要 心源性休克是一个毁灭性的问题，其住院死亡率相对停滞不前。 在过去的十年中，这一比例为30%-40%。因此，出现了一系列机械支持策略来缓解 多器官低灌注症。其中，经皮静脉-动脉体外膜 氧合(VA-ECMO)正日益被用于治疗心源性休克，因为它具有 在心导管实验室迅速建立，并提供大容量完整的血流动力学 和呼吸支持。然而，这种战略有显著的缺点，即与以下方面相关的高成本 它的计划发展和在重症患者中引入医源性并发症的可能性 人口。 先前来自动物模型的有创血流动力学数据表明，左室有恶化。 VA-ECMO血流动力学开始后几分钟内卒中作功增加所致的表现 支持。也有临床观察数据表明，VA-ECMO可能会加剧左室扩张 支持。相反，来自我们小组先前经验的人类数据表明，VA-ECMO在 院外心脏骤停后脉动最小的患者可以显著改善心脏恢复 以及神经学上有利的存活率。 这些相互矛盾的数据导致了包括VA-ECMO在内的各种管理战略的出现 因急性心肌梗死或心脏骤停而发生心源性休克的患者。在快速增长的背景下 VA-ECMO的用法迫切需要确定VA-ECMO影响心脏的方式 心源性休克时的血流动力学。 为了实现这一目标，我们将实现以下具体目标： 1.定义不同VA-ECMO支持水平下的LV压力容积面积(PVA)和每搏输出量 3例因CS行插管。2.明确延长VA-ECMO时左室搏动作业量的时间变化 在住院期间提供支持。暂时性恢复模式将与临床相关 拔管或过渡到永久性心脏辅助装置/移植或死亡的硬性终点。 3.与非侵入性采集的数据进行比较，验证无创重建PV-Loop的准确性 帮助建立一种更简单的方法来评估每天练习的LV卒中工作。 这项研究计划的预期结果是确定VA-ECMO支持的生理效应 并提供了客观科学的临床证据，源于高死亡率和 发病率患者群体。此外，我们预计我们的数据将有助于建立规范性 评估VA-ECMO患者的血流动力学和成像原理及策略。

Project Summary/Abstract Cardiogenic shock is a devastating problem that has had a relatively stagnant in-hospital mortality around 30-40% in the last decade. Consequently, an array of mechanical support strategies has emerged to mitigate the multi-organ hypoperfusion. Among them, percutaneous veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is increasingly being used to treat cardiogenic shock due to its capacity to be instituted rapidly in the cardiac catheterization laboratory and provide large volume complete hemodynamic and respiratory support. However, this strategy has notable disadvantages, namely high cost associated with its programmatic development and the potential for introducing iatrogenic complications in a very sick population. Prior invasive hemodynamic data from animal models have suggested that there is deterioration of LV performance due to increased stroke work within minutes of the commencement of VA-ECMO hemodynamic support. There is also observational clinical data showing that LV distension may worsen with VA-ECMO support. Conversely, human data from our group’s prior experience have suggested that VA-ECMO support in patients with minimal pulsatility after out-of-hospital cardiac arrest can dramatically improve cardiac recovery and rates of neurologically favorable survival. These conflicting data have led to the emergence of diverse management strategies including VA-ECMO in patients with cardiogenic shock either due to AMI or cardiac arrest. In the context of the rapidly increasing usage of VA-ECMO usage there is a critical need to identify the manner in which VA-ECMO affects cardiac hemodynamics in the setting of cardiogenic shock. To that goal we will pursue the following specific aims: 1. Define the LV pressure volume area (PVA) and stroke work at different levels of VA-ECMO support in patients cannulated for CS. 2. Define the temporal changes of LV stroke work with prolonged VA-ECMO support over the course of the hospitalization. The temporal recovery patterns will be associated with clinical hard endpoints of decannulation or transition to permanent cardiac assist devices/transplant or death. 3.Validate the accuracy of non-invasive reconstruction of PV-loops compared to invasively collected data to help establish an easier way to assess LV stroke work for every day practice. The expected outcome of this research proposal is to define the physiologic effect of VA-ECMO support on the left ventricle energetics and provide objective scientific clinical proof derived from a high mortality and morbidity patient population. Additionally, we expect that our data will be useful to establish normative hemodynamic and imaging principles and strategies for assessing patients on VA-ECMO.