LAUSR

e822 www.ccmjournal.org August 2018 • Volume 46 • Number 8 pressure also lead to a decrease in coronary perfusion and aggravate myocardial ischemia. Cui et al (1) also encourage the use of an intra-aortic balloon pump (IABP) to be used as an LV unloading device. The IABP is included in our algorithm as well, but we encountered several problems with this approach. First, aortic valve opening must be documented by imaging when an IABP is inserted additionally to a veno-arterial extracorporeal membrane oxygenation (VAECMO). Second, an IABP combined with a peripheral VA-ECMO will reduce upper extremity perfusion. If flow in the supra-aortic vessels is sufficient (in absence of oxygenation problems), you might have already reached a stage of cardiac recovery where VAECMO support is no longer needed and it can be weaned. In our hands, we could rarely document aortic valve opening with echocardiography when peripheral VA-ECMO was combined with IABP. Our approach is to achieve LV unloading with the combination of peripheral VA-ECMO with an axial left ventricular pump device like the Impella. There are two noncontrolled studies support this approach (3, 4). The authors’ suggestion to document intermittent aortic valve opening by reducing VA-ECMO pump speed in certain time intervals to prevent firm thrombus in the aortic root is interesting, but we do not believe that this adequately addresses the underlying problem (enhanced afterload duo to VA-ECMO induced by inverted blood flow). In situations with severe cardiac dysfunction and nonejecting heart, we do not recommend a surgical LV vent, as this might even further reduce flow across the aortic valve. Our approach would be the insertion of an LV unloading device such as the Impella, which establishes flow in the ascending aorta, prevents pulmonary congestions, and restores physiologic pulmonary flow to some extent. In addition, in such end-stage situations, cardiac recovery is unlikely, and the primary goal must be to prevent embolic events and to protect the lung, as this will be the limiting factors for further therapy such as left ventricular assist device implantation and heart transplantation. Dr. Hunziker disclosed off-label product use of the Impella pump (no U.S. Food and Drug Administration approval to be used in combination with venoarterial extracorporeal membrane oxygenation). Dr. Grübler has disclosed that he does not have any potential conflicts of interest