Preface

Extracorporeal membrane oxygenation (ECMO), also known as extracorporeal life support (ECLS), has evolved from a salvage form of life support, used only in cases in which all other therapies have failed, to a mainstream therapy for patients experiencing acute cardiac and/or respiratory failure. Initial experiences were associated with poor outcomes and few survivors. Challenges to success included difficulties in optimal patient selection, crudely designed and implemented technologies, an unclear understanding of the relationship between the patient and the extracorporeal circuit, lack of management guidelines, and difficulties in managing complications and guiding patients. However, over the past 20−30 years, there has been a growing recognition of the potentially life‐saving benefits of the role of extracorporeal support in allowing the failing heart/lungs to heal, possibly allowing for recovery or serving as a bridge to more definitive end‐organ replacement therapy such as ventricular assist devices or transplantation. This evolution has reflected a long journey, one that continues to evolve in part due to the hard work, dedication, and overall commitment of those who recognize the tremendous potential of ECMO to bring hope and restore life to those who would otherwise die.

ECMO is a rapidly evolving and extremely complex technology. With a better understanding of the technology, the indications for support, patient selection, surgical approach, and ECMO management, the outcomes will continue to improve.

Developing a comprehensive "ECMO team" is the first step in building a successful program. This team must be prepared to initiate therapy at any time and in any setting, from those as controlled as an operating room to those as chaotic as an emergency room. While the specific members of the team might vary from program to program, there are several key features that must be established in advance. It is well recognized that effective teams must communicate and work well together. There must be uniform trust and a collective value attached to the expertise that each member brings to the bedside. Additionally, there must be a willingness to embrace the concepts of crew resource management (CRM). The foundation of CRM is that every member of the team has a voice and that each voice is valued and respected. All members of the team must be encouraged, if not empowered, to speak up, particularly when there are safety concerns. In the context of an ECMO team, membership must include all ECMO-related disciplines.

This book discusses general clinical topics related to the specifics of therapy. There are chapters on cardiogenic shock, severe acute respiratory distress syndrome, and generalized applications for longer-term support. The book also addresses the fundamental differences between veno-veno ECMO (VV-ECMO) for pulmonary support and veno-arterial ECMO (VA-ECMO) for cardiac or cardiopulmonary support. This

book reflects the collective teamwork of those individuals worldwide who have dedicated countless energy to achieving a better understanding of those ECMO details that will ultimately yield better outcomes.

> **Dr. Antonio Loforte, MD, Ph.D.,** Chair, Mechanical Circulatory Support (MCS) Program, Department of Surgical Sciences, University of Turin, Turin, Italy City of Health and Sciences Hospital Turin, University Division of Cardiac Surgery,

> > Heart and Lung Transplant Center,

Turin, Italy

**Chapter 1**

*Gabriella Rovero*

**Abstract**

**1. Introduction**

metabolic shock.

systolic function.

ous systemic perfusion and oxygenation.

ECMO in Cath-Lab for Coronary,

Percutaneous Cardiac Interventional

This chapter describes the use of ECMO for interventional cardiology procedures.

In recent years, the rapid development of these techniques has allowed treatment of extremely complex patients, not subject to traditional cardiac surgery due to the very high operational risk which was, therefore, intended only for palliative medical therapy. These procedures are carried out by a multidisciplinary team composed of an interventional cardiologist, heart surgeon, anaesthetist, and perfusionist who

**Keywords:** ECMO, complex intervention, heart failure, invasive cardiac support, TAVI

Veno-arterial extracorporeal membrane oxygenation (V-A ECMO) is a temporary, mechanical, circulatory, and respiratory support system. Its main use is in patients with heart and/or respiratory failure, allowing complete support by ensuring continu-

This support system has traditionally been used as "rescue" therapy in patients with cardiogenic shock. However, ECMO implantation in emergency conditions is burdened by relevant mortality and morbidity, due to high vascular complications and reduced coronary reserve of patients with severe aortic stenosis or complex coronary artery disease, especially in the presence of a reduction of the global systolic function. In these cases, prolonged hypotension can lead to a rapid deterioration of hemodynamic conditions with the development of cardio-

Recently, the use of ECMO as support during percutaneous complex cardiac interventions has been proposed, especially in high-risk patients. Besides the clinical aspects, also some technical issues have to be taken into account, such as complex anatomies with an extensive ischemic area at risk and severe impaired ventricular

collaborate closely during all phases of the patient's hospitalisation.

Structural or Combined

High-Risk Procedure
