Central extracorporeal life support with integrated left ventricular vent in children with low cardiac output: Pathophysiologic considerations

Introduction: For children with low cardiac output, extracorporeal life support (ECLS) is the mainstay of mechanical circulatory support. In this study, we reviewed our experience in central ECLS with integrated LV vent in children with intractable cardiac failure.

Methods and results: In 2011 – 2012, 8 children acquired temporary support via a central ECLS with integrated LV vent. All children have low cardiac output, either following cardiac surgery (n = 4) or during acute cardiac decompensation (n = 4). All cases are approached through median sternotomy. Arterial cannula was placed in ascending aorta and the right atrium was cannulated for venous return. LV vent was inserted through right superior pulmonary vein and connected to the venous line on ECLS, so that active left heart decompression was achieved. No patient died while on ECLS, 7 patients were successfully weaned from it and 1 patient was transitioned to a Berlin Heart BiVAD. 1 patient died while in hospital, despite successful wean from ECLS. Sternal wound infection occurred in none of the patients. Although culture-proven bacterial infections occurred in 3 patients in our series, all responded to specifically directed antibiotics.

Table 1: Patients demographic and surgery

Age	Diagnosis	Performed surgery; ECLS duration (d)
13 y	Acute myocarditis	ECLS impl.; 6 d
12 y	Dilatative cardiomyopathy, s/p mitral valve reconstruction	ECLS impl.; 10 d
1 mo	Tetralogy of Fallot with pulmonary artery atresia and MAPCAs	MAPCAs-Unifocalisation, transannular patch repair, ECLS impl.; 5 d
4 mo	Bland-White-Garland-Syndrom	Left coronary artery translocation, ECLS impl.; 5 d
3 mo	Complete AVSD Typ A, Trisomy 21	cAVSD repair, postoperative ECLS impl. in ICU; 8 d
9 y	Acute myocarditis	ECLS impl.; 5 d
2 y	Acute myocarditis, IGF-1 insufficiency (Laron-type dwarfism)	ECLS impl.; 9 d
4 mo	Inlet VSD, Trisomy 21	VSD patch closure, mitral valve inspection, ECLS impl.; 6 d

Conclusions: In the setting of low cardiac output and insufficient interatrial shunt, additional LV decompression via LV vent could avoid the left heart distension and might promote myocardial recovery. It helps to prevent pulmonary congestion and its associated pulmonary hemorrhage. In pulmonary dysfunction, separate blood gas analysis from the venous cannula and LV vent allows the monitoring of pulmonary recovery and helps to recognize the possible coronary hypoxia when the LV begins to recover. Based on our experience, we recommend the use of central ECLS with an integrated LV vent in children with low cardiac output.