Ramp-Down/Ramp-Up Protocol for Biventricular Dysfunction Management With ECpella Support

Benedetta Vitali Rosati; Camilla Dinale; Alessandro Barbaria; Umberto Di Dedda; Tommaso Aloisio; Giulio Mondellini; Christiaan Meuwese; Carolina Giordano; Marco Ranucci; Nicolas Van Mieghem; Michele Mondino; Roberto Lorusso; Paolo Meani

doi:10.1016/j.jaccas.2025.104153

Ramp-Down/Ramp-Up Protocol for Biventricular Dysfunction Management With ECpella Support

Benedetta Vitali Rosati, Camilla Dinale, Alessandro Barbaria, Umberto Di Dedda, Tommaso Aloisio, Giulio Mondellini, Christiaan Meuwese, Carolina Giordano, Marco Ranucci, Nicolas Van Mieghem, Michele Mondino, Roberto Lorusso, Paolo Meani^*

^*Corresponding author for this work

Research output: Contribution to journal › Article › Academic › peer-review

Abstract

Objective: Managing severe biventricular dysfunction with venoarterial extracorporeal membrane oxygenation (ECMO) and Impella requires a strategic approach. The ramp-down/ramp-up protocol standardizes care for such complex cases. Key Steps: Key monitoring tools include pulmonary artery catheter echocardiography (transesophageal echocardiography/transthoracic echocardiography), end-tidal CO<inf>2</inf>, invasive blood pressure, and blood gases. The primary goal is to ensure adequate oxygen delivery with mixed venous oxygen saturation (>65%). After stabilization (6-12 hours), ventricular function is evaluated every 12 hours to adjust ECMO and Impella support. Right ventricular function is assessed by progressively reducing ECMO, whereas left ventricular function is evaluated by gradually reducing Impella support. Potential Pitfalls: Impella flow is low at the onset due to left ventricular edema or right ventricular dysfunction. Although the protocol does not guarantee myocardial recovery, it can guide subsequent weaning or bridging strategies. Take-Home Message: The current ramp-down/ramp-up protocol individualizes cardiovascular support and minimizes hemodynamic complications.

Original language	English
Article number	104153
Number of pages	7
Journal	JACC. Case reports
Volume	30
Issue number	19
DOIs	https://doi.org/10.1016/j.jaccas.2025.104153
Publication status	Published - 16 Jul 2025

Keywords

cardiogenic shock
Impella
left ventricular unloading
mechanical circulatory support (MCS)
venoarterial extracorporeal membrane oxygenation (V-A ECMO)

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10.1016/j.jaccas.2025.104153Licence: CC BY-NC-ND

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@article{19efed94b8e246a691e12bf4625f9d92,

title = "Ramp-Down/Ramp-Up Protocol for Biventricular Dysfunction Management With ECpella Support",

abstract = "Objective: Managing severe biventricular dysfunction with venoarterial extracorporeal membrane oxygenation (ECMO) and Impella requires a strategic approach. The ramp-down/ramp-up protocol standardizes care for such complex cases. Key Steps: Key monitoring tools include pulmonary artery catheter echocardiography (transesophageal echocardiography/transthoracic echocardiography), end-tidal CO2, invasive blood pressure, and blood gases. The primary goal is to ensure adequate oxygen delivery with mixed venous oxygen saturation (>65\%). After stabilization (6-12 hours), ventricular function is evaluated every 12 hours to adjust ECMO and Impella support. Right ventricular function is assessed by progressively reducing ECMO, whereas left ventricular function is evaluated by gradually reducing Impella support. Potential Pitfalls: Impella flow is low at the onset due to left ventricular edema or right ventricular dysfunction. Although the protocol does not guarantee myocardial recovery, it can guide subsequent weaning or bridging strategies. Take-Home Message: The current ramp-down/ramp-up protocol individualizes cardiovascular support and minimizes hemodynamic complications.",

keywords = "cardiogenic shock, Impella, left ventricular unloading, mechanical circulatory support (MCS), venoarterial extracorporeal membrane oxygenation (V-A ECMO)",

author = "\{Vitali Rosati\}, Benedetta and Camilla Dinale and Alessandro Barbaria and \{Di Dedda\}, Umberto and Tommaso Aloisio and Giulio Mondellini and Christiaan Meuwese and Carolina Giordano and Marco Ranucci and \{Van Mieghem\}, Nicolas and Michele Mondino and Roberto Lorusso and Paolo Meani",

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year = "2025",

month = jul,

day = "16",

doi = "10.1016/j.jaccas.2025.104153",

language = "English",

volume = "30",

journal = "JACC. Case reports",

issn = "2666-0849",

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TY - JOUR

T1 - Ramp-Down/Ramp-Up Protocol for Biventricular Dysfunction Management With ECpella Support

AU - Vitali Rosati, Benedetta

AU - Dinale, Camilla

AU - Barbaria, Alessandro

AU - Di Dedda, Umberto

AU - Aloisio, Tommaso

AU - Mondellini, Giulio

AU - Meuwese, Christiaan

AU - Giordano, Carolina

AU - Ranucci, Marco

AU - Van Mieghem, Nicolas

AU - Mondino, Michele

AU - Lorusso, Roberto

AU - Meani, Paolo

PY - 2025/7/16

Y1 - 2025/7/16

N2 - Objective: Managing severe biventricular dysfunction with venoarterial extracorporeal membrane oxygenation (ECMO) and Impella requires a strategic approach. The ramp-down/ramp-up protocol standardizes care for such complex cases. Key Steps: Key monitoring tools include pulmonary artery catheter echocardiography (transesophageal echocardiography/transthoracic echocardiography), end-tidal CO2, invasive blood pressure, and blood gases. The primary goal is to ensure adequate oxygen delivery with mixed venous oxygen saturation (>65%). After stabilization (6-12 hours), ventricular function is evaluated every 12 hours to adjust ECMO and Impella support. Right ventricular function is assessed by progressively reducing ECMO, whereas left ventricular function is evaluated by gradually reducing Impella support. Potential Pitfalls: Impella flow is low at the onset due to left ventricular edema or right ventricular dysfunction. Although the protocol does not guarantee myocardial recovery, it can guide subsequent weaning or bridging strategies. Take-Home Message: The current ramp-down/ramp-up protocol individualizes cardiovascular support and minimizes hemodynamic complications.

AB - Objective: Managing severe biventricular dysfunction with venoarterial extracorporeal membrane oxygenation (ECMO) and Impella requires a strategic approach. The ramp-down/ramp-up protocol standardizes care for such complex cases. Key Steps: Key monitoring tools include pulmonary artery catheter echocardiography (transesophageal echocardiography/transthoracic echocardiography), end-tidal CO2, invasive blood pressure, and blood gases. The primary goal is to ensure adequate oxygen delivery with mixed venous oxygen saturation (>65%). After stabilization (6-12 hours), ventricular function is evaluated every 12 hours to adjust ECMO and Impella support. Right ventricular function is assessed by progressively reducing ECMO, whereas left ventricular function is evaluated by gradually reducing Impella support. Potential Pitfalls: Impella flow is low at the onset due to left ventricular edema or right ventricular dysfunction. Although the protocol does not guarantee myocardial recovery, it can guide subsequent weaning or bridging strategies. Take-Home Message: The current ramp-down/ramp-up protocol individualizes cardiovascular support and minimizes hemodynamic complications.

KW - cardiogenic shock

KW - Impella

KW - left ventricular unloading

KW - mechanical circulatory support (MCS)

KW - venoarterial extracorporeal membrane oxygenation (V-A ECMO)

U2 - 10.1016/j.jaccas.2025.104153

DO - 10.1016/j.jaccas.2025.104153

M3 - Article

SN - 2666-0849

VL - 30

JO - JACC. Case reports

JF - JACC. Case reports

IS - 19

M1 - 104153

ER -

Ramp-Down/Ramp-Up Protocol for Biventricular Dysfunction Management With ECpella Support

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Keywords

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