Modelling and Simulation of the Interactions Between the Cardiovascular System and the Combined Use of VA ECMO and IABP: Comparison Between Peripheral and Central Configurations

Veno-arterial extracorporeal membrane oxygenation (VA ECMO) for the management of refractory cardiogenic shock (CS) has been widely used in recent years. Increased left ventricular (LV) afterload induced by retrograde flow remains a limiting factor, which is particularly evident during peripheral VA ECMO support. The concomitant use of the intra-aortic balloon pump (IABP) is an established strategy to achieve LV unloading during VA ECMO support. Nevertheless, there remains controversy about the combined use of IABP during central or peripheral VA ECMO in terms of beneficial effects and outcome. We developed a simulation setting to study left ventricular unloading with IABP during peripheral and central VA ECMO using CARDIOSIM©, an established software simulator of the cardiovascular system. The aim was to quantitatively evaluate potential differences between the two VA ECMO configurations and ascertain the true beneficial effects compared to VA ECMO alone. The combined use of central VA ECMO and IABP decreased left ventricular end systolic volume and left ventricular end diastolic volume by 5-10%; right ventricular end systolic volume and right ventricular end diastolic volume by 10-20%; left atrial end systolic volume and left atrial end diastolic volume by 5-10%. Up to 25% reduction in mean left atrial pressure, up to 15% reduction in pulmonary capillary wedge pressure and up to 25% reduction in mean pulmonary arterial pressure was observed. From an energetic point of view, left ventricular external work decreased by 10-15% whilst up to 40%vreduction in right ventricular external work was observed. The findings make central VA ECMO plus IABP the most appropriate combination for left and right ventricle unloading.