Evolving Therapies and Technologies in Extracorporeal Membrane Oxygenation Left Arterial Venoarterial Extracorporeal Membrane Oxygenation: The Hemodynamic Implications and Current Practice Methodology

Abstract

Since its inception, venoarterial extracorporeal membrane oxygenation (VA-ECMO) has proved to play a pivotal role in providing mechanical circulatory support (MCS) in the setting of refractory cardiac failure. However, the retrograde flow often leads to further deleterious effects with increased afterload, left ventricle (LV) distension, LV wall stress, pulmonary edema, and higher myocardial oxygenation requirements. In lieu of this, an alternative cannulation method has been gaining momentum to provide MCS while simultaneously offloading the LV. Left arterial venoarterial (LAVA)-ECMO utilizes a novel insertion technique of combining left atrial and right atrial drainage and returning this blood supply in oxygenated form to the arterial circulation. This degree of unloading provides simultaneous biventricular unloading and adequate circulatory flow to help rest and allow for possible native heart recovery. This chapter serves as a vehicle for the description of the LAVA-ECMO, but also to discuss the physiology, implementation, cannulation strategies, complications, and implications of the methodology for utilizing this unique technique.