Integrated Echo-Hemodynamic Framework for VA-ECMO in Right Ventricular Infarction

Right ventricular (RV) myocardial infarction with cardiogenic shock presents complex management challenges. We present 3 cases illustrating a potential integrated approach combining pulmonary artery pulsatility index (PAPI) and RV-pulmonary artery coupling ratios (tricuspid annular systolic velocity/pulmonary artery systolic pressure, tricuspid annular plane systolic excursion/pulmonary artery systolic pressure) for venoarterial extracorporeal membrane oxygenation decision-making. Case 1 (PAPI = 0.47) and case 2 (PAPI = 0.64) required venoarterial extracorporeal membrane oxygenation with successful weaning when PAPI exceeded 1.5. Case 3 (PAPI = 1.05) was managed conservatively. In case 2, inhaled nitric oxide (iNO) improved PAPI during weaning. In case 3, iNO caused paradoxical deterioration necessitating discontinuation. Based on these observations, we suggest that PAPI and coupling ratios provide complementary information: PAPI reflects hemodynamic reserve, whereas coupling ratios assess intrinsic RV function. Neither parameter alone is sufficient; integration of both guides clinical decisions. Prospective validation is needed. For iNO use without mechanical support, adequate left ventricular reserve is critical; PAPI decline mandates immediate discontinuation.