Laurence Busse, MBA, MD, FCCM
Assistant Professor
Emory University School of Medicine, United States
Disclosure information not submitted.
Caitlin Ten Lohuis, ACNP
Acute Care Nurse Practitioner
Emory University
Atlanta, Georgia
Disclosure information not submitted.
Title: The Effect of Angiotensin II in Venovenous versus Venoarterial Extracorporeal Membrane Oxygenation
Introduction: Extracorporeal membrane oxygenation (ECMO) can support the cardiovascular and pulmonary systems, depending on the modality deployed. Veno-arterial (VA) ECMO is commonly utilized in for insufficient cardiac output, whereas veno-venous (VV) ECMO is utilized to help oxygenate blood during pulmonary failure. Angiotensin II (Ang II) is a vasopressor that is commonly used in both situations requiring VA ECMO and VVECMO when circulatory shock is present. Additionally, it may be more effective where angiotensin-converting enzyme (ACE) deficiency is present such as in pulmonary failure, because ACE is bound to the pulmonary endothelium. As such, Ang II may be more efficacious during VV ECMO due to pulmonary failure than during VA ECMO in settings of decreased cardiac output. The objective of this study is to describe the effectiveness of Ang II in VV ECMO versus VA ECMO.
Methods: This retrospective single center analysis included adults (≥18 years) receiving Ang II in the setting of VV (n=4) or VA (n=4) ECMO between October 2018 and June 2021. Data were summarized with descriptive statistics.
Results: Eight patients with average (SD) age of 53.8 (13.4), mostly male (n=7), with a mean SOFA score of 11.5 (3.7) were included in the analysis. Indications for VA ECMO included RV injury (n=1), STEMI (n=2) and septic cardiomyopathy (n=1). Indications for VV ECMO included aspiration pneumonia (n=1), influenza pneumonia (n=2), and hypoxic respiratory failure (n=1). At Ang II initiation, the mean (SD) PaO2/FiO2 ratio in the VA ECMO cohort was 428.5 (95.7) versus 135 (26.5) in the VV ECMO cohort. Six hours after Ang II was started, average norepinephrine equivalent (NE) catecholamine support fell from 0.50 to 0.36 mcg/kg/min (a 28.6% reduction) in the VA ECMO population and from 0.69 to 0.45 mcg/kg/min (a 33.9% reduction) in the VV ECMO population. All eight patients died.
Conclusions: Despite evidence of pulmonary dysfunction in the VV ECMO cohort, similar reductions in NE catecholamine support were seen in a cohort of VA ECMO patients compared to VV ECMO patients. The effect of Ang II on patient outcomes in the setting of VV versus VA ECMO remains unclear.