Abstract
Objectives: Venoarterial (VA) ECMO has emerged as a successful modality for bridging patients with critical cardiogenic shock to durable support. However, LV distention on ECMO impairs RV and lung recovery and can result in the need for a temporary RVAD. Additionally, patients on VA ECMO with organ dysfunction may require ongoing LV assistance for recovery prior to durable LVAD conversion. Placement of a large apical LV vent allows bedside conversion to LVAD and provides time for organ recovery prior to elective durable device implantation. Hypothesis: We hypothesized that LV venting on ECMO accelerates RV recovery, hastening conversion to LVAD. Methods: ECMO cases from January 2012 to April 2014 were reviewed following IRB approval. Sixteen patients met INTERMACS Category 1 criteria who were placed on VA ECMO for cardiogenic or post-cardiotomy shock. Eight patients had LV venting and eight had standard peripheral cannulation. Refractory pulmonary edema, CPR during cannulation, and severe LV distention were indications for LV venting. A 32 French malleable cannula was placed by limited anterolateral thoracotomy into the LV apex. Bedside LVAD conversion was performed by percutaneous decannulation of the venous line and removal of oxygenator from circuit. Results: Conversion to temporary LVAD was successful in all LV vent cases at a mean timepoint of 5.9 (±1.3) days after LV venting compared with 13.5 (±4.9) days in non-vented patients (p = 0.07). RVAD requirement was 25% in non-vented patients and 0% in vented patients. 30-day mortality was 25% for both groups. Conclusions: LV venting as an adjunct to VA ECMO facilitates RV recovery to enable early LVAD conversion at the bedside. It also provides organ recovery time and obviates the need for a temporary RVAD at the time of durable LVAD implantation. In conclusion, the LV apical venting technique allows staged recovery of critically ill patients in biventricular and multiple organ failure with a high survival rate.
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