Acute and Critical Care

Review Article

Cardiology
Left ventricle unloading during veno-arterial extracorporeal membrane oxygenation: review with updated evidence: Yongwhan Lim, Min Chul Kim, In-Seok Jeong; Acute Crit Care. 2024;39(4):473-487. Published online November 18, 2024; DOI: https://doi.org/10.4266/acc.2024.00801

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Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is widely used to treat medically refractory cardiogenic shock and cardiac arrest, and its usage has increased exponentially over time. Although VA-ECMO has many advantages over other mechanical circulatory supports, it has the unavoidable disadvantage of increasing retrograde arterial flow in the afterload, which causes left ventricular (LV) overload and can lead to undesirable consequences during VA-ECMO treatment. Weak or no antegrade flow without sufficient opening of the aortic valve increases the LV end-diastolic pressure, and that can cause refractory pulmonary edema, blood stagnation, thrombosis, and refractory ventricular arrhythmia. This hemodynamic change is also related to an increase in myocardial energy consumption and poor recovery, making LV unloading an essential management issue during VA-ECMO treatment. The principal factors in effective LV unloading are its timing, indications, and modalities. In this article, we review why LV unloading is required, when it is indicated, and how it can be achieved.

Citations

Citations to this article as recorded by

Routine Left Ventricular Unloading During Venoarterial Extracorporeal Membrane Oxygenation—A Therapeutic Conundrum
Alice Bottussi, Jacopo D'Andria Ursoleo, Enrica Piazza, Edoardo Mongardini, Fabrizio Monaco
Journal of Cardiothoracic and Vascular Anesthesia.2025; 39(3): 860. CrossRef
Transaortic Catheter Venting for Left Ventricular Unloading in Veno-Arterial Extracorporeal Life Support: A Porcine Cardiogenic Shock Model
Sang Yoon Kim, Hyoung Woo Chang, Jae Hang Lee, Jae Hyun Jeon, Yoohwa Hwang, Hwan Hee Park, Dong Jung Kim
Medicina.2025; 61(4): 552. CrossRef
Left Heart Venting or Unloading Strategies for VA-ECMO Patients: Indications, Timing, and Techniques: A Narrative Review
YeongEun Jo, Jiae Seong, Hwa-Jin Cho, Do Wan Kim, Yongwhan Lim, Yang Hyun Cho, Seunghwan Song, Min Chul Kim, Inseok Jeong
Journal of Cardiovascular Intervention.2025;[Epub] CrossRef
Strategies of Revascularization and Mechanical Circulatory Support for Acute Myocardial Infarction Complicated by Cardiogenic Shock: A Systematic Review With Updated Evidence
Yongwhan Lim, Min Chul Kim, Seok Oh, Joon Ho Ahn, Seung Hun Lee, Dae Young Hyun, Kyung Hoon Cho, Doo Sun Sim, Young Joon Hong, Juhan Kim, Youngkeun Ahn
Journal of Cardiovascular Intervention.2025;[Epub] CrossRef
Left ventricular unloading strategies in venoarterial extracorporeal membrane oxygenation patients: how much do we truly understand?
Jihyuk Chung, Su Yong Kim, Juhyun Lee, Yang Hyun Cho
Acute and Critical Care.2025; 40(2): 357. CrossRef

Original Articles

Pulmonary
Comparison of preoxygenation with a high-flow nasal cannula and a simple face mask before intubation in Korean patients with head and neck cancer: Jun-Young Jo, Jungpil Yoon, Heeyoon Jang, Wook-Jong Kim, Seungwoo Ku, Seong-Soo Choi; Acute Crit Care. 2024;39(1):61-69. Published online January 26, 2024; DOI: https://doi.org/10.4266/acc.2022.01543

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Abstract PDF Supplementary Material: Background
Although preoxygenation is an essential procedure for safe endotracheal intubation, in some cases securing sufficient time for tracheal intubation may not be possible. Patients with head and neck cancer might have a difficult airway and need a longer time for endotracheal intubation. We hypothesized that the extended apneic period with preoxygenation via a high-flow nasal cannula (HFNC) is beneficial to patients who undergo head and neck surgery compared with preoxygenation with a simple mask.
Methods
The study was conducted as a single-center, single-blinded, prospective, randomized controlled trial. Patients were divided into groups based on one of the two preoxygenation methods: HFNC group or simple facemask (mask group). Preoxygenation was performed for 5 minutes with each method, and endotracheal intubation for all patients was performed using a video laryngoscope. Oxygen partial pressures of the arterial blood were compared at the predefined time points.
Results
For the primary outcome, the mean arterial oxygen partial pressure (PaO2 ) immediately after intubation was 454.2 mm Hg (95% confidence interval [CI], 416.9–491.5 mm Hg) in the HFNC group and 370.7 mm Hg (95% CI, 333.7–407.4 mm Hg) in the mask group (P=0.002). The peak PaO2 at 5 minutes after preoxygenation was not statistically different between the groups (P=0.355).
Conclusions
Preoxygenation with a HFNC extending to the apneic period before endotracheal intubation may be beneficial in patients with head and neck cancer.

Epidemiology
Outcomes of extracorporeal membrane oxygenation support in pediatric hemato-oncology patients: Hong Yul An, Hyoung Jin Kang, June Dong Park; Acute Crit Care. 2024;39(1):108-116. Published online January 24, 2024; DOI: https://doi.org/10.4266/acc.2023.01088

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Abstract PDF Supplementary Material

Background
In this study, we reviewed the outcomes of pediatric patients with malignancies who underwent hematopoietic stem cell transplantation (HSCT) and extracorporeal membrane oxygenation (ECMO).
Methods
We retrospectively analyzed the records of pediatric hemato-oncology patients treated with chemotherapy or HSCT and who received ECMO in the pediatric intensive care unit (PICU) at Seoul National University Children’s Hospital from January 2012 to December 2020.
Results
Over a 9-year period, 21 patients (14 males and 7 females) received ECMO at a single pediatric institute; 10 patients (48%) received veno-arterial (VA) ECMO for septic shock (n=5), acute respiratory distress syndrome (ARDS) (n=3), stress-induced myopathy (n=1), or hepatopulmonary syndrome (n=1); and 11 patients (52%) received veno-venous (VV) ECMO for ARDS due to pneumocystis pneumonia (n=1), air leak (n=3), influenza (n=1), pulmonary hemorrhage (n=1), or unknown etiology (n=5). All patients received chemotherapy; 9 received anthracycline drugs and 14 (67%) underwent HSCT. Thirteen patients (62%) were diagnosed with malignancies and 8 (38%) were diagnosed with non-malignant disease. Among the 21 patients, 6 (29%) survived ECMO in the PICU and 5 (24%) survived to hospital discharge. Among patients treated for septic shock, 3 of 5 patients (60%) who underwent ECMO and 5 of 10 patients (50%) who underwent VA ECMO survived. However, all the patients who underwent VA ECMO or VV ECMO for ARDS died.
Conclusions
ECMO is a feasible treatment option for respiratory or heart failure in pediatric patients receiving chemotherapy or undergoing HSCT.

Citations

Citations to this article as recorded by

Extracorporeal Membrane Oxygenation in the Management of Tumor Lysis Syndrome in Children: A Review of Cases
Zere Aidynbek, Erken Kakenov, Olga Mironova, Karlygash Ydyrysheva, Tatyana Li, Vitaliy Sazonov
Journal of Clinical Medicine.2025; 14(8): 2771. CrossRef

Review Article

CPR/Resuscitation
Plasma biomarkers for brain injury in extracorporeal membrane oxygenation: Shrey Kapoor, Anna Kolchinski, Aaron M. Gusdon, Lavienraj Premraj, Sung-Min Cho; Acute Crit Care. 2023;38(4):389-398. Published online November 29, 2023; DOI: https://doi.org/10.4266/acc.2023.01368

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Abstract PDF: Extracorporeal membrane oxygenation (ECMO) is a life-saving intervention for patients with refractory cardiorespiratory failure. Despite its benefits, ECMO carries a significant risk of neurological complications, including acute brain injury (ABI). Although standardized neuromonitoring and neurological care have been shown to improve early detection of ABI, the inability to perform neuroimaging in a timely manner is a major limitation in the accurate diagnosis of neurological complications. Therefore, blood-based biomarkers capable of detecting ongoing brain injury at the bedside are of great clinical significance. This review aims to provide a concise review of the current literature on plasma biomarkers for ABI in patients on ECMO support.

Original Articles

Pulmonary
Combining reservoir mask oxygenation with high-flow nasal cannula in the treatment of hypoxemic respiratory failure among patients with COVID-19 pneumonia: a retrospective cohort study: Ivan Gur, Ronen Zalts, Yaniv Dotan, Khitam Hussain, Ami Neuberger, Eyal Fuchs; Acute Crit Care. 2023;38(4):435-441. Published online November 23, 2023; DOI: https://doi.org/10.4266/acc.2023.00451

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Abstract PDF Supplementary Material: Background
Concerns regarding positive-pressure-ventilation for the treatment of coronavirus disease 2019 (COVID-19) hypoxemia led the search for alternative oxygenation techniques. This study aimed to assess one such method, dual oxygenation, i.e., the addition of a reservoir mask (RM) on top of a high-flow nasal cannula (HFNC).
Methods
In this retrospective cohort study, the records of all patients hospitalized with COVID-19 during 2020–2022 were reviewed. Patients over the age of 18 years with hypoxemia necessitating HFNC were included. Exclusion criteria were positive-pressure-ventilation for any indication other than hypoxemic respiratory failure, transfer to another facility while still on HFNC and “do-not-intubate/resuscitate” orders. The primary outcome was mortality within 30 days from the first application of HFNC. Secondary outcomes were intubation and admission to the intensive care unit.
Results
Of 659 patients included in the final analysis, 316 were treated with dual oxygenation and 343 with HFNC alone. Propensity for treatment was estimated based on background diagnoses, laboratories and vital signs upon admission, gender and glucocorticoid dose. Inverse probability of treatment weighted regression including age, body mass index, Sequential Organ Failure Assessment (SOFA) score and respiratory rate oxygenation index showed treatment with dual oxygenation to be associated with lower 30-day mortality (adjusted hazard ratio, 0.615; 95% confidence interval, 0.469–0.809). Differences in the secondary outcomes did not reach statistical significance.
Conclusions
Our study suggests that the addition of RM on top of HFNC may be associated with decreased mortality in patients with severe COVID-19 hypoxemia.

Pulmonary
Outcomes of patients with COVID-19 requiring extracorporeal membrane oxygenation and continuous renal replacement therapy in the United States: Carlos R Franco Palacios, Rudiona Hoxhaj, Catlyn Thigpen, Jeffrey Jacob, Atul Bhatnagar, Asif Saberi; Acute Crit Care. 2023;38(3):308-314. Published online August 30, 2023; DOI: https://doi.org/10.4266/acc.2023.00115

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