Objectives: Dual mechanical support combining veno-arterial (VA) ECLS and Impella microaxial
pump rescues high-risk patients in refractory cardiogenic shock and biventricular
failure. An implantation of a permanent ventricular assist device (VAD) is a life-saving
procedure for these patients if cardiac function does not recover under biventricular
unloading. However, many questions centering on perioperative right heart failure
(RHF) and stabilization of right ventricular function remain elusive. Here, we compared
continuation of common VA ECLS via femoral access with a transvenous implantation
technique of a temporary right heart bypass (RHB) for patients undergoing LVAD implantation
after dual mechanical support.
Methods: We analyzed the results of patients undergoing LVAD implantation after successful
bridging with dual mechanical support jointly using VA ECLS combined with Impella
microaxial pump between March 2013 and June 2017. For perioperative stabilization
of right heart function, patient group 1 was kept on common VA ECLS after LVAD implantation.
Group 2 received a common ECLS circuit and transvenously implanted cannulas. The outflow
cannula was implanted via the femoral vein placed for drainage in the right atrium.
The 15French Bio-Medicus inflow cannula was inserted via the right jugular vein and
placed in the pulmonary artery (PA).
Results: Twenty-four patients (male n = 19; median age 56 year; range 17–70) with refractory cardiogenic shock required
biventricular mechanical support as a bridge-to-LVAD. The mean time on ECLS therapy
was 8 days; range 0–49 days. The mean time on Impella microaxial pump was 6 days;
range 1–15 days. In group 1 (n = 18) the VA ECLS therapy was continued in eighteen patients (75%) after LVAD implantation.
The mean time on the VA ECLS after LVAD was 7 days; range 1–21. Within this group
twelve patients died (67%) and six patients survived (33%). Group 2 (n = 6) received a temporary percutaneous RHB during LVAD implantation. The mean time
on RHB was 8 days; range 4–18. In this group one patient died (17%) and five survived
(83%).
Conclusion: In conclusion, high risk patients with refractory cardiogenic shock and double mechanical
support via VA- ECMO and Impella microaxial pump can be bridged successfully to a
LVAD implantation. For stabilization of the perioperative right heart function a percutaneously
installed transvenous RHB seems to provide better outcomes compared with patients
with continuation of the VA ECLS.
