Regarding the Letter to the Editor from Ariza-Solé et al, in which they offer their point of view concerning the article we published in Revista Española de Cardiología,1 we would like to add the following comments and reflections.
The use of a ventricular assist device with extracorporeal membrane oxygenation (VA-ECMO) for hemodynamic support in high-risk percutaneous coronary interventions and electrical storm can, as we show in our experience, be a valuable tool compared with other types of support. Intraaortic balloon counterpulsation is the oldest and simplest method, but its efficacy in patients with cardiac indices lower than 2 L/min/m2 is questioned. In these cases, the next option in the range of mechanical support measures comprises two devices: Impella® and ECMO plus VA. Percutaneous Impella® produces an increase in cardiac output of 2.5-4.0-5.0 liters and, although its cost is approximately 3-fold higher than that of VA-ECMO, the device appears to be effective for the performance of angioplasty in high-risk patients.2 However, in patients in whom femoral access is not possible or those having severe aortic stenosis, which were the cases in our patients nos. 1 and 4, respectively, its use is not possible.
The implantation of VA-ECMO is considered to be an aggressive technique because of the vascular complications derived from the size of the cannulas and the hematologic complications inherent in an extracorporeal circuit. In our experience, these complications are minimized by limiting the use of VA-ECMO to the duration of the procedure, ensuring safety and hemodynamic stability when they are technically difficult, in unstable and very high-risk patients. Moreover, the possibility of providing partial circulatory support enables the use of smaller cannulas, reducing the rate of vascular complications.
Finally, we subscribe to the initiative proposed by Ariza-Solé et al concerning the creation of a high-quality, prospective, multicenter registry to gather all the available experience with the use of VA-ECMO in the different clinical scenarios associated with the cardiology patient. Once again, the idea is to extend the utilization of this strategy for circulatory support in cardiac critical care units.
FUNDINGThis study was partly funded by the European Regional Development Fund (FEDER-UE)/Instituto de Salud Carlos III (ISCiii) and the Red de Investigación Cardiovascular (RIC) (Cardiovascular Research Network) (RD12/0042), Spain.