**2.1 Main indications for the prophylactic use of ECMO**


#### *ECMO in Cath-Lab for Coronary, Structural or Combined Percutaneous Cardiac Interventional... DOI: http://dx.doi.org/10.5772/intechopen.105933*

transplant surgery) are exposed to a very high risk of acute respiratory failure with minimal cardiac defiance during the revascularization procedure. Other left ventricular assistance systems, such as the Impella (axial pump, without the possibility of adding an oxygenator), are, therefore, not sufficient to guarantee that the procedure will be safely carried out, unlike ECMO, which allows the patient to be kept alert, spontaneously breathing with stable hemodynamic.


## **3. Pre-procedural phase**

A "Heart Team" made up of interventional cardiologists, cardiac surgeons, clinical cardiologists, cardio anesthesiologists and perfusionists discusses the clinical characteristics of all patients. The traditional cardiac surgery option is excluded due to the high operative risk (Euroscore II, STS score, and Syntax score), and the percutaneous option is chosen for the treatment of the diseases in question. But even these procedures are not free from risks, and in certain situations (clinical or technical), it is necessary to carry them out using mechanical assistance to the circulation. Several factors push the Heart Team to perform coronary or percutaneous valve procedures in ECMO assistance, [27] including acute heart failure, hemodynamic instability, reduced ejection fraction, need for support with inotropic drugs, extremely high surgical risk, technical aspects, particularly, for complex myocardial revascularizations with large areas of myocardial risk and risk of haemodynamic destabilisation during the procedure. Hemodynamic instability is defined as the need for inotropic drugs to maintain an average arterial pressure > 65 mmHg, while electrical instability refers to the presence of relapses of ventricular arrhythmias sustained in the last 24 hours.

In addition to routine instrumental and laboratory tests (ECG, chest x-ray, blood chemistry with control of blood counts, renal and hepatic function, and a particular focus on coagulation screening), a transthoracic or transoesophageal echocardiogram is performed if required by the underlying pathology. All patients are then subjected to an aortic CT angiography, which allows to evaluate the course, calibres, presence, and extent of atheromasia/calcifications or other alterations (e.g., aneurysms and thrombotic apposition) along the entire arterial tree and, therefore, allows to choose which is the best site for the assistance installation.

In some patients, especially those who are suffering from valvular pathologies with reduced ejection fraction and/or pulmonary hypertension, the infusion of Levosimendan in the 24–48 hours preceding the procedure may be useful in order to make them arrive at the best possible compensation conditions for the procedure. This may favour the weaning of the patient from extracorporeal circulation and limit or in any case reduce the need for the use of inotropic drugs in the intra- or postprocedural period.
