**5. ECMELLA approach**

Implantation of microaxial catheter-based devices, such as Impella (Abiomed Inc., Danvers, MA, and USA), provides temporary MCS with simultaneous LV

#### **Figure 1.**

*Single arterial access ECMELLA cannulation.*

unloading [12]. The combination of Impella and v-a ECLS, so-called ECMELLA approach provides advanced cardiopulmonary support in cardiogenic shock patients and has been demonstrated to significantly improve the outcomes compared to ECLS use alone [4, 11, 12]. Impella devices (Impella 2.5, CP, 5.0, and 5.5) are directly placed in the LV via the aortic valve, providing an anterograde blood flow and unloading in contrast to an ECLS [1, 2, 12]. Thereby, Impella within the ECMELLA approach enhances the support concept to a cardiocirculatory, rather than just a circulatory support system [13].

The Impella 2.5 and CP devices are placed percutaneously and support the hemodynamic with 2.5 up to 4.3 L/min. The surgically implanted Impella 5.0 and 5.5 models are able to generate full circulatory support with up to 5.5 L/min of blood flow. In the case of ECMELLA approach, an Impella flow of 1–2 L/min is usually enough for a sufficient LV unloading [10]. However, the application of more powerful Impella models can be beneficial, since it allows a de-escalation therapy meaning gradual ECLS weaning and explantation during increased Impella support and patients' mobilization [14].

Nevertheless, ECMELLA is associated with some vascular complications [4]. The necessity of additional arterial access increases the risk of access site bleeding, hematoma, dissections, and infections [4]. The ECMELLA 2.0 technique aims to reduce that issues, by utilization of a single arterial access technique. In this case, a Y-shaped vascular prosthesis is anastomosed to the patient's subclavian artery. One branch of the graft is used for Impella insertion, while the arterial cannula of ECLS is placed via the second side branch (**Figure 1**) [13, 15]. This method allows advanced cardiopulmonary support with flow rates above 10 L/min, providing biventricular unloading at the same time [13]. Another major advantage of this technique is the possibility for bedside de-escalation and ECLS explanation, which can be performed in local anesthesia and does not require surgical re-opening of the wound [10, 16].

Further improvement of the single-site ECMELLA approach is the ECMELLA 2.1 technique, with the percutaneous cannulation of the jugular vein for blood drainage. This approach allows patients' mobilization on ongoing support for an extended period of time (**Table 1**) [17].


#### **Table 1.**

*Comparison of different LV unloading strategies.*

*Left Ventricular Unloading in v-a ECLS Patients DOI: http://dx.doi.org/10.5772/intechopen.106349*
