Conventional versus pump-controlled retrograde trial off (PCRTO) weaning in V-A ECMO: exploring feasibility, physiological insights and benefits

Perfusfind S.L.
Artículos, ECMO art Jan 1, 1970 0

Abstract

Weaning from veno-arterial extracorporeal membrane oxygenation (V-A ECMO) and determining the optimal timing for liberation from mechanical circulatory support (MCS) remain critical yet complex. Although multiple weaning protocols exist, focusing on hemodynamic and echocardiographic parameters [1], no direct comparative studies have clarified which approach best reflects true cardiopulmonary reserve. Conventional weaning involves gradually reducing ECMO flow to around 1 L-per-minute (lpm), leaving 1 lpm residual right ventricular (RV) unloading and 1 lpm left ventricular (LV) afterload. In contrast, Pump-Controlled-Retrograde-Trial-Off (PCRTO) introduces controlled retrograde flow through the ECMO-pump, creating a controlled arterio-venous shunt that better mimics native physiology.

We conducted a pilot multicentre evaluation of PCRTO’s feasibility, safety, and physiological insights compared to conventional weaning. The study was registered as service evaluation and conducted across three quaternary high-volume centres. Our cohort included 21 adult patients (mean age 49 ± 16 years; 57% male) supported with V-A ECMO for refractory cardiogenic shock (CS) between March 2023 and September 2024. Our inclusion criteria ensured that only patients demonstrating sufficient cardiopulmonary recovery and stable haemodynamics were considered for weaning. The PCRTO-protocol also incorporated regular echocardiographic assessments and invasive monitoring with a pulmonary artery catheter. Criteria for ‘readiness-to-wean’ required resolution of the underlying cause of CS, evidence of improving end-organ perfusion (renal and hepatic), serum lactate < 2 mmol/L, mean arterial pressure (MAP) > 60 mmHg, arterial pulse pressure > 15 mmHg, improving left ventricular outflow tract velocity-time integral (LVOT VTI), and absence of severe mitral or tricuspid regurgitation

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