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

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, 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.