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

项目总结/摘要 心源性休克是一个毁灭性的问题，有一个相对停滞的住院死亡率约 在过去的十年里，30-40%。因此，出现了一系列机械支助战略， 多器官灌注不足其中，经皮动静脉体外膜 氧合（VA-ECMO）越来越多地被用于治疗心源性休克，这是由于其能够 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 呼吸支持。然而，该策略具有显著的缺点，即与以下相关的高成本： 其方案的发展和引入医源性并发症的潜力，在一个非常生病 人口 先前来自动物模型的有创血流动力学数据表明， 由于VA-ECMO血流动力学开始后几分钟内的心搏功增加， 支持.还有观察性临床数据显示，VA-ECMO可能会加重LV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支持 在院外心脏骤停后具有最小搏动的患者可以显著改善心脏恢复 和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在内的多种管理策略的出现， 由于AMI或心脏骤停导致心源性休克的患者。在快速增长的背景下， VA-ECMO的使用迫切需要确定VA-ECMO影响心脏的方式 心源性休克时的血流动力学 为此，我们将努力实现以下具体目标： 1.定义不同VA-ECMO支持水平下的LV压力容积面积（PVA）和每搏作功， 为CS插管的患者。2.定义延长VA-ECMO时左室每搏作功的时间变化 在住院期间提供支持。时间恢复模式将与临床 拔管或过渡到永久性心脏辅助装置/移植或死亡的硬终点。 3.与有创收集的数据相比，验证PV环的无创重建的准确性， 帮助建立一种更简单的方法来评估每天练习的LV中风工作。 本研究提案的预期结果是确定VA-ECMO支持对以下患者的生理影响： 左心室能量学，并提供客观的科学临床证据，来自高死亡率， 发病率患者人群。此外，我们希望我们的数据将有助于建立规范的 评估VA-ECMO患者的血流动力学和成像原理和策略。

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.