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.