30 A . Calhoun et al .: J Extra Corpor Technol 2025 , 57 , 24 – 31
While most clinicians with VA-ECMO experience would likely agree that signs of significant congestion such as pulmonary edema , frothy secretions , and refractory ventricular arrhythmias would be indications for mechanical LV unloading , other criteria for earlier intervention are less straightforward which highlights the need for further research . At present , it may be that employing a combination of PAC-derived hemodynamics and ALPP monitoring is the optimal , most rapid , and reliable bedside surveillance method for the early detection of LVD ( See Fig . 1 ).
While not a systematic review , our literature search shows significant heterogeneity in definitions for the detection of LVD . It also shows a marked variation in thresholds for the initiation of LV mechanical unloading strategies . The available literature on mechanical LV unloading in patients undergoing VA-ECMO support for cardiogenic shock does not yet provide clarity on how best to proceed . At present , clinicians are faced with a dilemma regarding the risks and benefits of mechanical LV unloading strategies without a definitive reference on when and what type to initiate . It is additionally not known whether the optimal approach to mechanical LV unloading should be with early intervention ( for example , at the time of VA-ECMO cannulation ) or with watchful monitoring . LV unloading is a crucial part of VA-ECMO management in patients with cardiogenic shock and there is a critical need for further research on the subject . Further research on the pre-clinical diagnosis of LVD and triggers for LV unloading is of paramount importance to prevent the significant consequences of LVD while minimizing the risks of utilizing additional vascular access and procedures .
Funding
This research received no specific grant from any funding agency in the public , commercial , or not-for-profit sectors .
Conflicts of interest The authors declare no conflicts of interest .
Data availability statement
This was a literature review thus , no patient data that was not already publicly available published literature was collected .
Author contribution statement
Anthony Calhoun : Conceptualization , Methodology , Investigation , Writing – Original Draft , Writing – Reviewing and Editing , Visualization . Min-Ho Lee : Writing – Reviewing and Editing . Dominic Pisano : Writing – Reviewing and Editing . Alexandros Karavas : Conceptualization , Writing – Reviewing and
Editing .
Jamel Ortoleva : Conceptualization , Methodology , Investigation , Writing – Original Draft , Writing – Review and Editing , Visualization , Supervision .
Ethics approval
This review paper analyzed publicly available literature and did not involve the collection of new human participant data .
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