Q36 / 110
AMI shock includes severe LV dysfunction, moderate RV dysfunction, severe refractory hypoxemia, and lactate 8.2 mmol/L. Which strategy addresses all immediate problems?
Correct answer: C — Peripheral VA-ECMO
VA-ECMO supplies systemic flow, oxygenation, CO₂ removal, and right-sided support. A and D provide LV support without respiratory support. B is inadequate for profound combined cardiopulmonary collapse.
Board pearl: If the patient needs oxygenation as well as circulation, ECMO moves to the top.
VA-ECMO supplies systemic flow, oxygenation, CO₂ removal, and right-sided support. A and D provide LV support without respiratory support. B is inadequate for profound combined cardiopulmonary collapse.
Board pearl: If the patient needs oxygenation as well as circulation, ECMO moves to the top.
Q37 / 110
On maximal Impella CP support, renal function, lactate, and vasopressor requirements continue to worsen. What is the best next strategy?
Correct answer: C — Escalate to a higher level of MCS
On maximal Impella CP support, if renal function, lactate, and vasopressor requirements continue to worsen, the best next strategy is to escalate to a higher level of MCS. Impella CP on average provides flows up to approximately 3.5–4.0 L/min, while Impella 5.5 flows up to 5.5 L/min. The escalation should still be matched to whether the remaining problem is isolated LV failure, biventricular failure, or combined cardiopulmonary collapse.
Board pearl: Impella CP on average provides up to approximately 3.5–4.0 L/min, whereas Impella 5.5 can provide up to 5.5 L/min.
On maximal Impella CP support, if renal function, lactate, and vasopressor requirements continue to worsen, the best next strategy is to escalate to a higher level of MCS. Impella CP on average provides flows up to approximately 3.5–4.0 L/min, while Impella 5.5 flows up to 5.5 L/min. The escalation should still be matched to whether the remaining problem is isolated LV failure, biventricular failure, or combined cardiopulmonary collapse.
Board pearl: Impella CP on average provides up to approximately 3.5–4.0 L/min, whereas Impella 5.5 can provide up to 5.5 L/min.
Q38 / 110
During temporary BiVAD support with an RA-to-PA RVAD and an LVAD, echocardiography shows a dilated RV, an underfilled LV, and marked leftward bowing of the interventricular septum. CVP is elevated, and RVAD flow is lower than LVAD flow. Which pump adjustment best addresses this imbalance?
Correct answer: A — Increase RVAD flow
This pattern indicates inadequate right-sided support relative to LVAD flow, so increasing RVAD flow is the best first adjustment. Of note, both devices in BiVAD insertions can result in recirculation due to pulmonic and aortic insufficiency. The flows calibrated can be deceiving; however, we want to avoid over circulation of the pulmonary vasculature due to risk of severe pulmonary edema and pulmonary hemorrhage. Frequent evaluation with chest wall ultrasound or TEE may be necessary if changes to the setting or hemodynamic status are suspected.
Board pearl: Frequent evaluation with chest wall ultrasound or TEE may be necessary because the flows calibrated can be deceiving.
This pattern indicates inadequate right-sided support relative to LVAD flow, so increasing RVAD flow is the best first adjustment. Of note, both devices in BiVAD insertions can result in recirculation due to pulmonic and aortic insufficiency. The flows calibrated can be deceiving; however, we want to avoid over circulation of the pulmonary vasculature due to risk of severe pulmonary edema and pulmonary hemorrhage. Frequent evaluation with chest wall ultrasound or TEE may be necessary if changes to the setting or hemodynamic status are suspected.
Board pearl: Frequent evaluation with chest wall ultrasound or TEE may be necessary because the flows calibrated can be deceiving.
Q39 / 110
What design feature primarily contributes to the low pump-thrombosis rate of HeartMate 3?
Correct answer: B — Fully magnetically levitated centrifugal impeller
Full magnetic levitation eliminates mechanical bearings and helps reduce stasis, heat generation, and adverse shear, all of which contribute to the low pump-thrombosis rate of HeartMate 3. That stands in contrast to earlier continuous-flow designs that relied on bearing contact and carried higher thrombosis and stroke risk.
Board pearl: The signature engineering advance of HeartMate 3 is full magnetic levitation.
Full magnetic levitation eliminates mechanical bearings and helps reduce stasis, heat generation, and adverse shear, all of which contribute to the low pump-thrombosis rate of HeartMate 3. That stands in contrast to earlier continuous-flow designs that relied on bearing contact and carried higher thrombosis and stroke risk.
Board pearl: The signature engineering advance of HeartMate 3 is full magnetic levitation.
Q40 / 110
Taken together, what do current VA-ECMO unloading studies support?
Correct answer: B — Unloading is physiologically attractive and observationally associated with benefit, but randomized evidence remains limited
Taken together, current VA-ECMO unloading studies support that unloading is physiologically attractive and observationally associated with benefit, but randomized evidence remains limited. See the Ezad et al. review (https://www.ahajournals.org/doi/10.1161/CIRCULATIONAHA.122.062371) for the key review and ongoing studies. This is a field with strong physiology and encouraging observational data, but not yet definitive universal randomized guidance.
Board pearl: Current support for unloading is still best understood through the physiology and review literature summarized in the Ezad et al. review (https://www.ahajournals.org/doi/10.1161/CIRCULATIONAHA.122.062371).
Taken together, current VA-ECMO unloading studies support that unloading is physiologically attractive and observationally associated with benefit, but randomized evidence remains limited. See the Ezad et al. review (https://www.ahajournals.org/doi/10.1161/CIRCULATIONAHA.122.062371) for the key review and ongoing studies. This is a field with strong physiology and encouraging observational data, but not yet definitive universal randomized guidance.
Board pearl: Current support for unloading is still best understood through the physiology and review literature summarized in the Ezad et al. review (https://www.ahajournals.org/doi/10.1161/CIRCULATIONAHA.122.062371).
Source(s): Ezad et al. Unloading the Left Ventricle in Venoarterial ECMO: In Whom, When, and How? Circulation. 2023 Apr;147(16). https://doi.org/10.1161/CIRCULATIONAHA.122.062371.