How Would We Treat Our Own Weaning From Microaxial Flow Pumps for Left Ventricular Unloading?

A personalized rather than "one-size-fits-all" approach is essential when weaning patients from microaxial flow pumps (Impella). We detail, for the first time, a structured, stepwise, multimodal, bedside strategy to guide safe and effective discontinuation from a microaxial flow pump, based on echocardiography, reconditioning, and use of inotropes, Impella support, stepwise reduction titrated according to hemodynamics, and lung ultrasound with VExUS when appropriate ("E.R.I.L." protocol). Integrating these 4 pillars into daily clinical practice, E.R.I.L. aims to identify the optimal timing for discontinuation of microaxial flow pump use, whether used as isolated mechanical circulatory support or combined with V-A ECMO (ECPELLA), thereby minimizing device-related complications while preserving the duration of support needed to achieve sustained left ventricular recovery.