Background: Assessing heart recovery and readiness for Venoarterial Extracorporeal Membrane Oxygenation (VA-ECMO) weaning is crucial but lacks standardization across institutions. In 2020, we implemented a standardized protocol for VA-ECMO weaning trial using our institution's Pump-Controlled Retrograde Trial Off (PCRTO). This study assesses the safety and efficacy of the PCRTO protocol for weaning adults from VA-ECMO support after cardiogenic shock (CS).
METHODS AND RESULTS: A retrospective analysis was conducted on adult patients who received VA-ECMO for CS between January 2020 and July 2023. Patients not eligible for the PCRTO trial were excluded (direct bridge to transplantation or durable left ventricular assist device, death under support, active hemodynamic or hemodynamic instability). Data included clinical characteristics, indications, weaning techniques, hemodynamics during PCRTO, complications, and outcomes. The primary safety endpoint was the incidence of complications during PCRTO, including bleeding, cardiac arrest, thromboembolism, or device-related issues. The efficacy endpoint was survival without escalation for hemodynamic instability 72h after VA-ECMO decannulation. Outcomes at 30 days were also analyzed. Among the 48 patients who received VA-ECMO support, 30 (63%) underwent PCRTO (median age: 55 years, 30% female) and were included. Common VA-ECMO indications included ischemic CS (n=13), acute on chronic heart failure (n=9), myocarditis (n=5), and arrhythmia-induced CS (n=3). Peripheral cannulation was used in all but one case, with a median ECMO duration of 138±66 hours. The primary safety endpoint was negative in all patients. Among the 28 patients (93%) weaned, 2 (7%) patients experienced clinical deterioration, and 1 (4%) died within 72 hours post-decannulation. The positive predictive value of PCRTO for safe decannulation at 72 hours was 89.3%. Overall survival was 75% and 71.5% at 30 and 90 days, respectively. No parameter was identified to discriminate patients with unsuccessful or successful VA-ECMO weaning.
Conclusion: PCRTO is a safe procedure for evaluating cardiac recovery and readiness for VA-ECMO weaning.
