Extracorporeal life support with left ventricular decompression—improved survival in severe cardiogenic shock: results from a retrospective study

Abstract

ObjectiveExtracorporeal life support (ECLS) is a life-saving procedure used in the treatment of severe cardiogenic shock. Within this retrospective single centre study, we examined our experience in this critically ill patient cohort to assess outcomes and clinical parameters by comparison of ECLS with or without selective left ventricular decompression.MethodsBetween 2004 and 2014 we evaluated 48 adult patients with INTERMACS level 1 heart failure (age 49.7 ± 19.5 years), who received either central ECLS with (n = 20, 41.7%) or ECLS without (n = 28, 58.3%, including 10 peripheral ECLS) integrated left ventricular vent in our retrospective single centre trial.ResultsFollow up was 100% with a mean of 0.83 ± 1.85 years. Bridge to ventricular assist device was feasible in 29.2% (n = 14), bridge to transplant in 10.4% (n = 5) and bridge to recovery in 8.3% (n = 4). Overall 30-day survival was 37.5%, 6-month survival 27.1% and 1-year survival 25.0%. ECLS support with left ventricular decompression showed favourable 30-day survival compared to ECLS without left ventricular decompression (p = 0.034). Thirty-day as well as long-term survival did not differ between the subgroups (central ECLS with vent, ECLS without vent and peripheral ECLS without vent). Multivariate logistic regression adjusted for age and gender revealed ECLS without vent as independent factor influencing 30-day survival.ConclusionECLS is an established therapy for patients in severe cardiogenic shock. Independent of the ECLS approach, 30-day mortality is still high but with superior 30-day survival for patients with ECLS and left ventricular venting. Moreover, by unloading the ventricle, left ventricular decompression may provide an important time window for recovery or further treatment, such as bridge to bridge or bridge to transplant.

Left Ventricle Unloading with Veno-Arterial Extracorporeal Membrane Oxygenation for Cardiogenic Shock. Systematic Review and Meta-Analysis

“…Briefly, the left atrium can be drained surgically by a cannula in the left atrial roof or in the right superior pulmonary vein or percutaneously [32,55] by an interatrial septostomy (septostomy usually with ballooning or stent) or a cannula attached to the ECMO venous return or to device like TamdemHeart ® ). Direct left ventricle unloading can be also achieved or by a surgical cannulation of the ventricle apex [56,57] and through the mitral valve from the left atrium [56,58] or percutaneously by a catheter across the aortic valve. The surgical or percutaneous pulmonary artery cannulation [56,57], increasing the right-side blood drainage, will indirectly reduce the pulmonary venous return and left cardiac chamber loading.…”

Clinical outcomes of venoarterial extracorporeal life support in 462 patients: Single‐center experience

“…Schmack et al also assessed the outcomes and clinical parameters by comparing ECLS with or without selective LV decompression in a cohort of 48 patients in refractory CS. ECLS with left ventricular decompression showed favorable 30‐day survival ( P = .034) . We did not see any difference regarding the application of LV decompression in our study cohort.…”

Left ventricular decompression in veno-arterial extracorporeal membrane oxygenation

“…Several studies have compared elective LV venting to no venting on VA-ECMO support. In a study of 48 adult patients by Schmack et al [2017], 20 patients on central VA-ECMO support underwent LV decompression via the right upper PV (20). The LV vent was inserted during ECMO cannulation, and repeat echocardiography post venting showed a reduction in LV size compared to patients who did not undergo decompression (20).…”

“…In a study of 48 adult patients by Schmack et al [2017], 20 patients on central VA-ECMO support underwent LV decompression via the right upper PV (20). The LV vent was inserted during ECMO cannulation, and repeat echocardiography post venting showed a reduction in LV size compared to patients who did not undergo decompression (20). Patients with a vent also had significantly higher 30-day survival (55% versus 25%, P=0.034), though there was no difference in mortality at 12 months and there were no differences in hepatic, renal, and pulmonary function (20).…”

“…The LV vent was inserted during ECMO cannulation, and repeat echocardiography post venting showed a reduction in LV size compared to patients who did not undergo decompression (20). Patients with a vent also had significantly higher 30-day survival (55% versus 25%, P=0.034), though there was no difference in mortality at 12 months and there were no differences in hepatic, renal, and pulmonary function (20). These results must be interpreted with caution, however, as several important baseline differences between the comparison groups were not controlled for, including younger age in the LV vent group, and a higher proportion of post-cardiotomy shock and IABP insertions in the non LV-vent group (20).…”