Prime time for veno-arterial extracorporeal membrane oxygenation in 24-7 interventional cardiology center?

Because of continuous improvements in emergency prehospital services, high-volume ST-elevation myocar-dial infarction (STEMI) networks are nowadays admitting increasing numbers of patients with hemodynamic deterioration including profound cardiogenic shock and refractory cardiac arrest. The intra-aortic balloon pump (IABP) unfortunately offers only limited hemodynamic support without evidence of improved outcomes in the randomized SHOCK-IABP trial [1]. Accordingly, in a busy 24-7 catheterization laboratory, there is an unmet need for an active full-flow device which can be quickly and easily implanted by an interventional cardiologist. Such a device would promptly stabilize a patient, allow subsequent percutaneous coronary intervention (PCI) in a more stable condition and buy time for myocardial recovery or serve as a bridge to a long-term assist device or heart transplantation. Various devices such as the Impella or TandemHeart, as well as veno-arterial extracorporeal membrane oxygenation (VA ECMO), are nowadays available. Each of these devices has advantages and disadvantages in terms of complexity, implantation procedure, hemodynamic characteristics, complications and costs. Importantly, none of the devices has yet been demonstrated to improve clinical outcomes, although available randomized trials are significantly underpowered. In this issue of the journal, Litwiński et al. report a non-ST-elevation myocardial infarction (NSTEMI) patient with life-threatening iatrogenic left main dissection during coronary angiography which could not be solved by stenting [2]. As expected, the patient immediately developed cardiogenic shock refractory to mechanical ventilation and inotropes. No hemodynamic support was used before or during the transport to a tertiary center, where he underwent immediate coronary artery bypass graft surgery (CABG). Despite surgical revascularization, severe left ventricular pump failure refractory to pharmacological treatment and IABP persisted. The patient was therefore put on postcardiotomy central VA ECMO for 14 days, survived to hospital discharge and is now a candidate for heart transplant. What can we learn from this case report? Obviously, with such an unresolved complication and without active circulatory support, the patient was very fortunate to survive transportation to a tertiary institution. I suspect there was a partial restoration of anterograde flow despite dissection, which, together with presence of the right dominant coronary system, kept him from refracto-ry cardiac arrest. The majority of such patients are not so lucky. This brings us to the question of whether it is necessary to have an effective hemodynamic support device in every 24-7 catheterization laboratory to bridge severe hemodynamic deterioration which may be present in some patients already at admission and persist despite successful …