Amirali Masoumi, MD, FACC, Medical Director of Cardiac Critical Care and Medical and Interventional Director of the Cardiogenic Shock and Mechanical Circulatory Support Program at Morristown Medical Center.
Early identification of cardiogenic shock is vital to securing the best possible outcomes for patients. Even patients who present with lab values and hemodynamic data that do not suggest cardiogenic shock may be in the early stages of it. Intervening quickly with innovative treatments can mean the difference between preserving end organ function and watching patients spiral down until life-saving salvage procedures become the only option.
Early care and the value of ECMO
Three columns define our approach to care in the Cardiogenic Shock and Mechanical Circulatory Support Program at Morristown Medical Center:
- Identify early– capture patients in the C and D stages of the Society for Cardiovascular Angiography and Interventions (SCAI) pyramid of cardiogenic shock, when the trajectory of disease can potentially be changed and consequences such as multi-organ failure avoided
- Stabilize early– deploy appropriate interventions to stabilize hemodynamics and preserve organ function, including extracorporeal mechanical oxygenation (ECMO) cannulation when appropriate
- Mobilize early – advance patients to the next stage of care as quickly as possible—such as a left ventricular assist device (LVAD), heart transplant, physical therapy, or even discharge home
To elucidate the value of ECMO as an early intervention, I recently delivered a presentation entitled From Surgical to Interventional: ECMO Cannulation Outside the OR at the THT 2025: Technology and Heart Failure Therapeutics conference in Boston.
Here, I share key insights from the presentation and how early identification of cardiogenic shock allows us to get creative in managing patients with ECMO.
ECMO: a quiet evolution
Since the introduction of the first ECMO circuit into the OR in 1971, the system has quietly evolved to become almost portable. Where once it was used for full bypass support in patients with induced cardioplegia, it is now routinely utilized at the bedside or in the cardiac catheterization lab in patients who are awake and communicative.
The adoption of ECMO support continues to grow in nonsurgical cases that require bypass because of acute myocardial infarction (AMI) shock, acute decompensated heart failure (HF), advanced HF, or other etiologies. ECMO delivers the highest level of support for patients sliding into degrees of shock.
Support for nonsurgical use of ECMO
I co-authored several publications that demonstrate differences in applying ECMO support in nonsurgical patients compared with those who have undergone surgery.
Unlike patients who undergo heart surgery, nonsurgical patients are not in postcardiotomy, or post-sternotomy, shock. This essentially changes the phenotype of both the patient and the shock.
Since its formation three years ago, our MMC Cardiogenic Shock Team has implemented many creative approaches to the utilization of ECMO in nonsurgical patients, based on the published evidence.
Creative approaches to ECMO outside the OR
Here are some of the ways we innovate at Morristown Medical Center to optimize our use of ECMO outside the OR.
Smaller cannula sizes
Leg ischemia is one of the most challenging risks to patients on ECMO. Contributing factors include large bore accesses, complicated care requirements, and higher rates of peripheral artery disease.
To help mitigate the risk of distal limb ischemia, we utilize smaller cannula sizes. In most cases, we have successfully minimized the incidence of distal limb ischemia while still providing adequate perfusion.
Published data and our own clinical experience support this approach.
Partial flow
Certain physiological factors help facilitate adequate perfusion rates with partial flow in ECMO patients outside the OR. Their pericardium, for example, remains mostly intact. As a result, their heart still contracts even if not at its best.
We continue to achieve adequate perfusion in a timely manner with partial flow—without damage or loss to end organs like the kidneys, liver, or brain. This has allowed us to serve our patients well and achieve robust outcomes.
Percutaneous cannulation/decannulation
We rely more and more on percutaneous techniques to decannulate ECMO patients outside the OR. Doing so helps us:
- Eliminate surgical cutdowns
- Minimize patient discomfort
- Improve the healing process
- Avoid surgical complications
Surgical backup is still vitally important for our patients. In many cases, our expert surgical team will intervene at some point. However, we have been very successful in avoiding surgical cutdowns by inserting and removing cannulas percutaneously.
No intubation/low sedation
As much as possible, we cannulate patients under moderate sedation, avoiding intubation unless necessary. We think of ECMO cannulation as essentially analogous to undergoing an angiogram. Keeping patients awake, breathing on their own, and conversant helps minimize complications such as ventilator-associated pneumonia and aspiration. It also allows patients to engage with their multidisciplinary care teams on complex care decisions about whether and how to move forward with advanced therapies. As clinicians, we can speak with patients, assess their awareness of the situation, and understand their desires for treatment.
Most importantly, care progresses forward faster when patients are awake because they can actively participate in their care and decision making. We do not lose precious time waking them, extubating them, and waiting for issues like post-intubation delirium to resolve so they have clear minds. Instead, we mobilize very quickly.
Time is always of the essence. Patients cannot remain on ECMO support for too long—complications will arise.
Alternate access sites
We want to make it as easy as possible for patients to engage in physical therapy on ECMO. For this reason, we avoid large bore accesses through the femoral artery whenever possible. Once a patient’s condition stabilizes, we move access to either the internal jugular or axillary artery in the shoulder. This frees up the patient’s groin, facilitating better standing and walking during physical therapy. We have excellent physical therapists who are dedicated to our cardiac intensive care patients. They utilize new, state-of-the-art equipment to help patients regain as much muscle strength as possible.
Innovating the future of ECMO
Future innovations I look forward to in ECMO include smaller circuits for a more portable system.
Engineers and industry leaders will hopefully develop true percutaneous cannulas that allow us to achieve higher flow rates, preserve end organ function, and more flexibly explore alte rnative access sites.
At Morristown, we are heavily focused on research. We recently joined the prestigious Cardiogenic Shock Working Group, an NIH-funded initiative, and are adding our high-quality data to the group’s robust database. We anticipate participating in many studies based on the data in the registry that will progress care for patients with cardiogenic shock.
Learn more about Interventional Cardiology at Morristown Medical Center.
Learn More button: https://ahs.atlantichealth.org/conditions-treatments/heart-care/treatment-services/interventional-cardiology.html