Effects of Surgical Left Ventricular Vent in Patients with Cardiogenic Shock Requiring Extracorporeal Membrane Oxygenation

Abstract

Purpose Venoarterial extracorporeal membrane oxygenation (VA ECMO) for the treatment of cardiogenic shock often requires left ventricular (LV) venting to decrease afterload and prevent LV distention. Percutaneous strategies for LV venting are limited by peripheral complications such as bleeding and lower limb ischemia as well as insufficient LV unloading. A surgical LV vent is an alternative option that may provide hemodynamic and clinical benefits. Methods This is a retrospective review of 33 patients with refractory cardiogenic shock requiring VA ECMO who underwent surgical LV vent placement between July 2015 and March 2020. Surgical LV vent was placed in the LV apex via left anterolateral thoracotomy. Patients were stratified according to the percutaneous vent strategy prior to LV vent placement, which included femoral VA ECMO alone (n = 7), ECMO plus intra-aortic balloon pump (IABP) (n = 10), or ECMO plus Impella (ECPELLA) (n = 16) sub-groups. The outcome of interest was immediate hemodynamic change with surgical LV vent placement as well as clinical outcomes. Results The most cited reasons for conversion to surgical LV vent included inadequate venting with percutaneous strategy, hypoxia, and bleeding from peripheral access site. Across all patients, surgical LV vent was associated with a decrease in diastolic pulmonary artery (PA) pressures (20 vs 16 mmHg, p = 0.01) along with an increase in SVO2 (69% vs 80.5%, p Conclusion The surgical LV vent can provide significant LV unloading in patients supported by VA ECMO for cardiogenic shock. Compared to percutaneous methods of LV unloading, the surgical LV vent can provide substantial unloading of the LV, improved oxygenation, and a greater degree of hemodynamic support with acceptable short-term outcomes.