Left Ventricular Decompression Research Articles

Anterolateral papillary muscle suction causing low flow in a COVID-19 patient without medical history: a case report of central extracorporeal life support with left ventricular apex decompression.

Left ventricular (LV) decompression is an essential strategy for improving early survival in patients with refractory cardiogenic shock. Low pump flow in patients on extracorporeal life support (ECLS) with LV apex decompression is a life-threatening issue. However, identifying the underlying causes of low flow can be challenging. A 38-year-old woman with COVID-19-related fulminant myocarditis was treated with central ECLS with LV apex decompression. The pump flow in the intensive care unit (ICU) was intermittently low, and low flow alerts were frequent. The initial evaluation based on pressure monitor waveforms and transthoracic echocardiography failed to identify the underlying cause. Prompt bedside transesophageal echocardiography (TEE) revealed that the anterolateral papillary muscle was suctioned into the vent cannula of the LV apex during systole. The patient underwent a repeat sternal midline incision in the operating room, and the cannula at the LV apex was repositioned. There were no further suction events after the repositioning, and the patient was weaned from ECLS 12days after admission to the ICU. The patient was discharged in a stable condition and without neurological deficits. TEE is an important diagnostic tool to identify the underlying cause of low flow flow in patients undergoing ECLS with LV apex decompression.

Left ventricular decompression in veno-arterial extracorporeal membrane oxygenation

Objective: Our study investigates the frequency and determines the characteristics and outcomes of patients with venoarterial extracorporeal membrane oxygenation (VA-ECMO) support requiring left ventricular unloading at Ha Noi Heart hospital.
 Methods: A cross-sectional descriptive study was conducted among 84 patients undergoing VA- ECMO between December 2018 and December 2021 at Ha Noi Heart hospital. Signs of left ventricular distension in VA-ECMO (Inadequate arterial blood pressure pulsatility, “smoke like” effect in left ventricular, reduced aortic valve opening/absent aortic valve closure, pulmonary edema, left ventricular distension) were studied before and at 24 hours, 48 hours and 72 hours after VA-ECMO support.
 Results: Left ventricular distention requiring decompression occurs in 44,1% of patients supported with VA-ECMO 3.6% (left ventricular distension), inadequate arterial blood pressure pulsatility (77,4%), “smoke like” effect in left ventricular (53,6%), pulmonary edema 47 ,6%; reduced aortic valve opening/absent aortic valve closure in 35,7% of the cases. Left ventricular decompression may improve clinical outcomes from 48 hours onwards (p<0.05). There were no differences in age, left ventricular ejection fraction before VA-ECMO, ECRP rates, continuous renal replacement therapy rates, duration of mechanical ventilation, duration of ECMO, hospital length of stay and diagnosis of patients with and without left ventricular unloading (p>0.05). The proportion of patients using invasive left ventricular decompression who successful weaning from VA- ECMO was significantly higher than in the group without left ventricular unloading (94,5% versus 74,4%; p<0.05).The survival rate of patients using left ventricular unloading tended to be higher than that in the group without left ventricular decompression (72,9% vs 53,2%; p>0.05) ). Complications of invasive left ventricular decompression included 1 patient with occlusion of the junction requires removal of the left atrial drainage.
 Conclusion: Left heart decompression may contribute to increasing the success rate of VA-ECMO weaning and may help to improve the survival rate of patients with VA ECMO.

Transaxillary implantation of a temporary microaxial left ventricular assist device in a patient with a rectangular kinked subclavian artery.

Transaxillary implantation of a temporary microaxial left ventricular assist device in patients suffering from cardiogenic shock is an established technique. We present a 77-year-old female patient with severe mitral regurgitation. She underwent minimally invasive surgical mitral valve replacement. After an uneventful postoperative course, the patient developed acute heart failure on the 11th postoperative day. Transthoracic echocardiography revealed new onset of takotsubo cardiomyopathy with a severely decreased left ventricular ejection fraction. Implantation of a microaxial flow pump for left ventricular decompression was scheduled. Preoperative computed tomography revealed a rectangular course of the right subclavian artery. To advance the Impella we employed an introducer fitted over the guidewire behind the Impella device as a 'cue stick' to move the rigid part of the pump forward to overcome the kinking using a 'shuffleboard technique'. The haemodynamic situation stabilized immediately after implantation. The Impella 5.5 was successfully weaned after six days of support. In the event of (rectangular) kinking of the subclavian artery, the 'shuffleboard technique' can be used for successful positioning of the pump.

Severe COVID-19-associated myocarditis with cardiogenic shock – management with assist devices – a case report & review

BackgroundPrimary viral myocarditis associated with severe acute respiratory syndrome coronavirus 2 (SARS-Cov2) infection is a rare diagnosis.Case presentationWe report the case of an unvaccinated, healthy patient with cardiogenic shock in the context of a COVID-19-associated myocarditis and therapy with simultaneous veno-arterial extracorporeal membrane oxygenation (VA-ECMO) and percutaneous left ventricular decompression therapy with an Impella. The aim of this review is to provide an overview of therapeutic options for patients with COVID-19-associated myocarditis.ConclusionsThe majority of patients required a combination of two assist devices to achieve sufficient cardiac output until recovery of left ventricular ejection fraction. Due to the rapid onset of this fulminant cardiogenic shock immediate invasive bridging therapy in a specialized center was lifesaving.

Central extracorporeal membrane oxygenation with left-ventricular vent for fulminant myocarditis: a retrospective study.

Fulminant myocarditis presents as acute severe heart failure and requires mechanical cardiocirculatory support. Left-ventricular (LV) decompression is necessary for the successful recovery of these patients. This retrospective study aimed to evaluate the functional outcomes of providing central extracorporeal membrane oxygenation (ECMO) with LV decompression for the treatment of refractory fulminant myocarditis. Between January 2015 and February 2021, seven consecutive fulminant myocarditis patients (mean age: 41.1 ± 26.1years) received central ECMO support with transapical LV decompression, with an 18 French cannula integrated into the ECMO circuit in a Y-fashion. The baseline characteristics and postoperative outcomes of the patients were collected. On admission, all patients received prior peripheral ECMO, and 85.7% (6/7) of patients received prior intra-aortic balloon pumping. However, all patients had refractory cardiogenic shock that failed prior to decompression. Six patients recovered successfully after a mean ECMO support of 20.0 ± 11.5days and five patients had no recurrence of cardiac decompensation. The mean ICU and mean hospital stays were 36.7 ± 23.5days and 60.6 ± 24.9days, respectively. Hospital mortality was 28.6% (2/7). Two patients died due to sepsis and stroke during hospitalization. Central ECMO with an LV vent was effective for fulminant myocarditis refractory to percutaneous cardiopulmonary support therapy and other therapies.

Early Mechanical Circulatory Support for Cardiogenic Shock.

Reversal of cardiogenic shock depends on its early recognition and prompt initiation of therapy. Recognition of the clinical and hemodynamic deterioration that precedes cardiogenic shock is a crucial step in its early detection. Treatment of pre-cardiogenic shock is chiefly pharmacologic with intravenous administration of pressor, inotropic, and loop diuretic agents. Failure to reverse the preshock state with pharmacotherapy entails progression to cardiogenic shock and the need for prompt mechanical circulatory support with membrane oxygenation and possibly left ventricular decompression.

Current status and future trends of left ventricular decompression strategies in veno-arterial extracorporeal membrane oxygenation

Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is a great weapon to save patients with acute heart failure. At present, in most cases, VA-ECMO is perfused through femoral artery intubation, and the external blood flow is opposite to the direction of cardiac ejection, which will increase the left ventricular afterload and lead to left ventricular expansion, which is not conducive to the recovery of cardiac function. This paper reviews the development course of left ventricular decompression at home and abroad, summarizes the present situation of left ventricular decompression technology at home and abroad, analysis of left ventricular decompression technology advantages and existing problems, and put forward their own opinions, to analyze the prevention and solution of left ventricular distension in VA-ECMO, may explore better method, improve the success rate of treatment in patients with heart failure.

P42: Institutional Review of Temporary Circulatory Support Configurations for Cardiogenic Shock

Patients experiencing cardiogenic shock continue to suffer a high mortality risk despite advances and innovation in temporary mechanical circulatory support (MCS). Providers now have many tools in the armamentarium to support patients in varied etiologies of cardiogenic shock ranging from acute coronary syndrome, non-ischemic cardiomyopathy (nICM) with end-stage heart failure and postoperative-cardiotomy biventricular dysfunction. Although instituting VA-ECMO rapidly restores circulation and perfusion in cardiopulmonary failure, alternative MCS configurations may be preferred depending on the unique etiology for cardiac decompensation. A retrospective observational review was performed on our institutional data for patients in cardiogenic shock requiring MCS stratifying into those receiving ECMO only versus VA ECMO and Impella (Ecpella) support. An analysis was conducted to evaluate whether metrics including ICU length of stay, days on CRRT ECMO and mechanical ventilation are affected by the MCS configuration in specific etiologies of cardiogenic shock. Charts were reviewed from present time to 2017 with inclusion criteria of patients having documentation of VA ECMO support. Patients who had ECMO for non-cardiac intraoperative arrests, septic shock or ARDS respiratory failure were excluded. 202 patient chart were included into the analysis in which patients received VA ECMO only or Ecpella support. Figure 1 delineates grouping into cohorts: ischemic cardiomyopathy (ICM) including acute coronary syndrome, non-ischemic cardiomyopathy (nICM), and postoperative cardiogenic shock. Data analyzed included duration of days on ECMO, CRRT and mechanical ventilation as well as ICU length of stay (LOS). Statistical analysis was performed using independent t-test to report significance between sample groups. The composite and stratified averages for the metrics in patients who survived are shown in tables 1 and 2. Although not statistically significant, the patients supported by Ecpella in the nICM cohort had reduced days on devices as well as ICU LOS. In contrast, patients receiving ECMO only in the ICM cohort had shorter days on devices and ICU LOS. The postoperative cardiogenic shock cohort did not appear to have any significant trends in the analyzed metrics. Composite mortality rate was 0.63 vs 0.72 in the ECMO only vs Ecpella group. nICM patients appear to benefit from ventricular unloading with impella support during MCS that allows for improved end-organ recovery as evident by shorter days on supportive devices while awaiting myocardial recovery versus bridge to durable therapy. In contrast, prompt restoration of perfusion in ICM patients with ECMO alone may facilitate and expedite myocardial recovery, obviating the need for a left ventricular decompression device. Further studies are necessary to confirm whether pathophysiologic differences of cardiogenic shock in nICM vs ICM cause recovery to be more receptive to particular MCS configurations.

Details of Targeted Temperature Management Methods for Patients Who Had Out-of-Hospital Cardiac Arrest Receiving Extracorporeal Cardiopulmonary Resuscitation: A Questionnaire Survey.

This study aimed to precisely describe the details of targeted temperature management (TTM) following extracorporeal cardiopulmonary resuscitation (ECPR) in patients with out-of-hospital cardiac arrest (OHCA). A questionnaire to examine the TTM details following ECPR was distributed to 36 medical institutions that participated in the Study of Advanced life support for Ventricular fibrillation with Extracorporeal circulation in Japan (SAVE-J) II study. The survey was conducted using an anonymous questionnaire through the Internet and was distributed in January 2021 and collected in February 2021. Practical TTM methods (induction, maintenance, and rewarming duration) and monitoring and management methods, such as target levels, drugs, left ventricular decompression therapy, nutrition, and rehabilitation therapy, were recorded. We received responses from all 36 institutions. The target temperature was initiated at 34°C in 72.2% of institutions. In ∼90% of institutions, the maintenance duration was 24 hours, which was also the leading duration of rewarming 24 hours (38.9%), followed by 48 hours (30.6%). Electroencephalogram is routinely applied in only 13.9% of institutions. Prophylactic antibiotics were used in 58.6% of institutions. Enteral nutrition during TTM is consistently initiated in 27.8% of institutions and 33.3% of institutions initiated enteral nutrition for patients without catecholamine requirements. The 24-48 hours (55.6%) was the leading period of initiating early rehabilitation, followed by <24 hours. This survey described the details of the current practice for treating patients with OHCA by TTM following ECPR. Since various factors were undetermined in the TTM, randomized controlled trials will be necessary to resolve issues during TTM following ECPR.

Contemporary national utilization of extracorporeal cardiopulmonary resuscitation (ECPR) for out-of-hospital cardiac arrest.

The utilization of extracorporeal membrane oxygenation (ECMO) during cardiopulmonary resuscitation (ECPR) has demonstrated promising evidence for the management of out-of-hospital cardiac arrest (OHCA). We aim to describe contemporary utilization and predictors of survival of patients receiving ECPR for OHCA. The National Inpatient Sample (NIS) was queried to identify hospital discharge records of patients aged ≥18 years who underwent ECPR from 2012 to 2017. Patients with an International Classification of Diseases, Tenth Revision, Clinical Modification diagnosis of cardiac arrest, admitted urgentlyand placed on ECMO on Day 0 of hospitalization, were selected. Patients with a primary diagnosis indicative of veno-venousECMO were excluded. Predictors of mortality were assessed using multivariable analyses. There were 1675 cases of ECPR, increasing from 185 cases in 2012 to 400 in 2017 (p < .001). Overall mortality was 63.3%, which remained stable over time (p = .441). Common diagnoses included ST-elevation myocardial infarction (39.1%), non-ST-elevation myocardial infarction (9.3%), and pulmonary embolism (13.7%). Percutaneous coronary intervention was performed in 495 patients (29.6%); coronary artery bypass grafting was performed in 125 patients (7.5%). In multivariable analysis, decreased age, female gender, and left ventricular (LV) decompression were associated with reduced mortality. Utilization of ECPR is increasing nationally with stable mortality rates. Younger age, female gender, and utilization of LV decompression were associated with increased survival.

ELSO Interim Guidelines for Venoarterial Extracorporeal Membrane Oxygenation in Adult Cardiac Patients.

ELSO Interim Guidelines for Venoarterial Extracorporeal Membrane Oxygenation in Adult Cardiac Patients.

Left Ventricular Decompression by Transaortic Catheter Venting in Extracorporeal Membrane Oxygenation.

Venoarterial extracorporeal membrane oxygenation (VA-ECMO) has been widely applied to patients with cardiogenic shock. Left ventricle (LV) decompression is important when LV distension develops with pulmonary edema. The purpose of this study was to present the results of transaortic catheter venting (TACV) performed during VA-ECMO. We retrospectively reviewed the medical records of 18 patients who underwent both VA-ECMO and TACV between January 2017 and December 2019. Venoarterial extracorporeal membrane oxygenation was applied uneventfully. Lactate level and norepinephrine requirement for patients of weaning success were lower than those of patients of weaning failure after the application of TACV (p = 0.032 and p = 0.015, respectively). The successful weaning rate of ECMO was 77.8% (15/18) and survival rate was 50% (9/18). Transaortic catheter venting may be an easy, safe, and effective technique for LV decompression in patients with VA-ECMO for cardiogenic shock. Also, this technique may be helpful as an alternative or bridge method.

Radiographic appearance of extracorporeal membrane oxygenations versus left ventricular assist device.

Chest radiography compares left ventricular decompression in the same patient supported with extracorporeal membrane oxygenation with atrial septal fenestration and subsequently supported with left ventricular assist device with apical cannulation.

A Case of Vascular Behcet's Leading to Cardiogenic Shock Requiring VA-ECMO

<h3>Introduction</h3> Vascular Behcet's (VB) is a rare inflammatory disorder with venous and less commonly arterial involvement. Coronary arteries are rarely involved. High clinical suspicion is required to make the diagnosis when the mucocutaneous manifestations of Behcet's are absent. <h3>Case Report</h3> A 45-year-old Portuguese male with prior unprovoked venous thromboembolism at the age of 30 presented with ST-elevation myocardial infarction and cardiogenic shock. Coronary angiography showed a large left main (LM) aneurysm with thrombus <i>(Figure 1A)</i>. He underwent LM balloon angioplasty and coronary artery bypass grafting. Postoperatively, he was placed on peripheral venoarterial-extracorporeal membrane oxygenation for cardiogenic shock with biventricular failure, as a bridge to decision. An intraoperative right ventricular biopsy showed only fibrinous pericarditis. He required septostomy for left ventricular decompression. Despite therapeutic heparinization, he was diagnosed with bilateral pulmonary emboli and occlusion of the common hepatic artery proper with suspected porta hepatis arterial aneurysm <i>(Figure 1B-C)</i>. He was found to carry the HLA-B51 allele and thus VB was favoured as a unifying diagnosis. Intravenous solumedrol was administered, but the patient developed anuric renal failure and limb ischemia. He ultimately succumbed to his illness due to septic shock with multiorgan failure. An autopsy confirmed the coronary aneurysm (<i>Figure 1D</i>) but could not confirm etiology. The hepatic aneurysm was not confirmed on autopsy due to technical challenges. <h3>Summary</h3> VB can lead to cardiac complications such as coronary aneurysms or thrombosis which may be the initial presentation in a smaller proportion of patients. Though immunosuppression is the mainstay of treatment, there is no established protocol and mortality/morbidity remain high. VB should be included in the differential diagnosis of a young patient presenting with coronary aneurysms to prompt appropriate therapy, though prognosis remains reserved.

Assisting the Heart to Assist the Lungs: LVAD Support in Restrictive Physiology and Pulmonary Hypertension

<h3>Introduction</h3> Pulmonary hypertension (PH) is a risk factor for mortality after heart transplantation (HTx). We present a case of treatment of post-capillary PH in a small pediatric patient with restrictive physiology using continuous flow ventricular assist device (VAD) support to achieve candidacy for HTx. <h3>Case Report</h3> A 4.5 year old female (0.57m²) with a history of acute myeloid leukemia and anthracycline chemotherapy in infancy developed mildly depressed left ventricular (LV) function at 2 years of age. Hemodynamic catheterization (cath) showed pre- and post-capillary PH secondary to LV diastolic dysfunction and restrictive physiology (Table). She was cautiously initiated on PDE5 inhibitor therapy (sildenafil) while maintaining LV reverse remodeling therapies. Her heart failure (HF) symptoms and biventricular systolic function worsened over the subsequent 2 years. Subsequent caths showed increasing PVRi, which was responsive to 100% FiO2 and inhaled nitric oxide (iNO), but also accompanied by increase in LV end-diastolic pressures (LVEDP). She was transitioned to endothelin receptor antagonist therapy (bosentan), but continued to worsen clinically, requiring initiation of milrinone. Due to her underlying restrictive physiology leading to worsening PH and severely depressed right ventricular (RV) function, a HeartWare HVAD (cannulation LV to Aorta) was implanted to allow aggressive optimization of PH therapies with simultaneous LV decompression. This enabled up-titration of bosentan as well as re-addition of sildenafil. After PH therapies including VAD implantation, PVRi decreased from a high of 10.7 WU.m2 to 4.7 WU.m2, and marked decline of LVEDP from 22 mmHg pre-VAD to 5 mmHg. She underwent HTx 6 months after VAD implantation, and was discharged home 12 days post-HTx on sildenafil. <h3>Summary</h3> VAD support in tandem with optimal PH therapies is a feasible strategy to treat post-capillary PH, optimize pulmonary vasculature to reduce RV dysfunction, and enable a successful bridge to HTx.

Hybrid and parallel extracorporeal membrane oxygenation circuits

Hybrid and parallel extracorporeal membrane oxygenation circuits

Hemodynamic adaptation of heart failure to percutaneous venoarterial extracorporeal circulatory supports.

Extracorporeal life support (ECLS) is a treatment modality that provides prolonged blood circulation, gas exchange and can partially support or fully substitute functions of heart and lungs in patients with severe but potentially reversible cardiopulmonary failure refractory to conventional therapy. Due to high-volume bypass, the extracorporeal flow is interacting with native cardiac output. The pathophysiology of circulation and ECLS support reveals significant effects on arterial pressure waveforms, cardiac hemodynamics, and myocardial perfusion. Moreover, it is still subject of research, whether increasing stroke work caused by the extracorporeal flow is accompanied by adequate myocardial oxygen supply. The left ventricular (LV) pressure-volume mechanics are reflecting perfusion and loading conditions and these changes are dependent on the degree of the extracorporeal blood flow. By increasing the afterload, artificial circulation puts higher demands on heart work with increasing myocardial oxygen consumption. Further, this can lead to LV distention, pulmonary edema, and progression of heart failure. Multiple methods of LV decompression (atrial septostomy, active venting, intra-aortic balloon pump, pulsatility of flow) have been suggested to relieve LV overload but the main risk factors still remain unclear. In this context, it has been recommended to keep the rate of circulatory support as low as possible. Also, utilization of detailed hemodynamic monitoring has been suggested in order to avoid possible harm from excessive extracorporeal flow.

Beating heart left ventricle thrombectomy through mini-left-anterior thoracotomy for a patient with cardiogenic shock.

Left ventricular (LV) thrombus is frequently occurred with dilated cardiomyopathy (DCM) when a patient receives extracorporeal membrane oxygenation (ECMO) support for cardiogenic shock. LV decompression techniques are sometimes required immediately after ECMO support. However, LV thrombus is a contra indication for LV assist device (LVAD). We planned a mini-left-anterior thoracotomy instead of using sternotomy, and used beating heart under ECMO support. LV was opened through apex and thrombectomy was performed by finger manipulation and the remained thrombus was removed by balloon guided technique. Our technique is a simple and durable method for removing LV thrombus under ECMO support and might be considered as a supplementary procedure before temporally LVAD.

Venoarterial Extracorporeal Membrane Oxygenation.

Venoarterial Extracorporeal Membrane Oxygenation.

The use of extracorporeal membrane oxygenation in children with acute fulminant myocarditis.

Acute fulminant myocarditis (AFM) occurs as an inflammatory response to an initial myocardial insult. Its rapid and deadly progression calls for prompt diagnosis with aggressive treatment measures. The demonstration of its excellent recovery potential has led to increasing use of mechanical circulatory support, especially extracorporeal membrane oxygenation (ECMO). Arrhythmias, organ failure, elevated cardiac biomarkers, and decreased ventricular function at presentation predict requirement for ECMO. In these patients, ECMO should be considered earlier as the clinical course of AFM can be unpredictable and can lead to rapid haemodynamic collapse. Key uncertainties that clinicians face when managing children with AFM such as timing of initiation of ECMO and left ventricular decompression need further investigation.