Transapical Left Ventricular Vent (TLVV) during veno-arterial ECMO support: a bridge to solution in acute cardiogenic shock

Abstract

Introduction: One of the main limitations of Veno-Arterial {ECMO} ({VA-ECMO)} support is the inappropriate unloading of the Left Ventricule ({LV).} The increased risk of pulmonary edema and impairs {LV} function reduces the possibility of a recovery or the feasibility of other definitive treatments such as permanent {LVAD} implantation or emergency heart transplantation. The solution proposed by our center is the surgical implantation of a transapical {LV} vent ({TLVV)} through a minimal invasive approach. {TLVV} reduces significantly the pulmonary edema and it gave the chance to convert {VA-} {ECMO} circuit to a short-term {LVAD} as a bridge to solution.Methods: From January 2010 to June 2012, 16 consecutive pediatric and adult patients supported by pheripheral {AV} {ECMO} for acute profound cardiogenic shock underwent {TLVV} implantation. Cannulation was done in the {ICU} through a mini-torachotomy with the seldinger technique using an arterial high-flow multiperforated cannula. {TLVV} was subsequently connected to the venous inflow line of the {AV} {ECMO.} The switch from {AV} {ECMO} to short term {LVAD} has been done in two stages: the weaning from the right circulatory support (intermediate stage: A-A {ECMO)} and the subsequent weaning from the oxygenator.Results: In-hospital mortality was%. In 12 patients (75,0%) pulmonary function significantly improved after implanting {TLVV} and the {VA} {ECMO} circuit was simplified to a short term {LVAD} through an intermediate stage of A-A {ECMO} in order to evaluate the right ventricular and the pulmonary function in two different times. Ten pts were successfully bridged to a definitive treatment: heart transplantation in 3 patients, permanent {LVAD} implantation in 2 patients and bridge to recovery in 5 patients. In hospital survival in patients arrived to these solutions was 8/10 (80,0%).Conclusions: In our series the double drenaige both of the right and the left side of the heart improved pulmonary function and it gave the possibility to switch from the {VA} {ECMO} to a short-term {LVAD} in the majority of cases. After clinical stabilization of patients it was possible to access to a definitive treatment. We think that in the setting of an {VA} {ECMO}, {TLVV} implantation is useful in order to identify the best candidate for permanent {LVAD}, heart transplantation or recovery reducing significantly the risk of unsuccess.