Transapical Left Ventricular Vent (TLVV) during Artero-Venous ECMO Support: A Bridge to Solution in Acute Cardiogenic Shock

Abstract

Purpose One of the main limitations of artero-venous ECMO (AV-ECMO) support is the inappropriate unloading of the left ventricle (LV). The increased risk of pulmonary edema and impairs LV function reduces the possibility of recovery or the feasibility of a permanent LVAD implantation or heart transplantation. The solution proposed is the surgical implantation of a transapical LV vent (TLVV) through a minimally invasive approach. TLVV reduces significantly the pulmonary edema and it gives the chance to convert AV- ECMO circuit to a short-term LVAD as a bridge to solution. Methods and Materials From January 2010 to June 2012, 16 patients supported by pheripheral AV ECMO for cardiogenic shock underwent TLVV implantation. Cannulation was done through a mini-torachotomy with the seldinger technique using an arterial high-flow cannula. TLVV was 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 47,5 %. In 12 patients (75,0%) pulmonary function significantly improved. AV ECMO circuit was simplified to a short term LVAD in 10 patients. Ten pts were 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 TLVV improved pulmonary function and it gave the possibility to switch from the A-V ECMO to a short-term LVAD. After clinical stabilization of patients it was possible to access to a definitive treatment. We think that in the setting of an AV 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.