Left heart decompression at venoarterial extracorporeal membrane oxygenation initiation in cardiogenic shock: prophylactic versus therapeutic strategy

Abstract

Background: We aimed to investigate the effects and proper timing of left heart decompression (LHD) on the clinical outcomes of patients on venoarterial extracorporeal membrane oxygenation (VA ECMO).

Methods: Among 335 adult patients who underwent VA ECMO from January 2013 to December 2016, 50 who underwent LHD were analyzed. The patients were divided into two groups according to the timing of LHD: those in whom percutaneous LHD was performed at ECMO initiation (prophylactic LHD group, n=18) and those who required LHD to treat complications of impaired left ventricle (LV) unloading (therapeutic LHD group, n=32).

Results: Thirty-day mortality rates were 34.4% and 5.6% in the therapeutic and prophylactic LHD groups, respectively (P=0.036). The rate of successful weaning from ECMO (62.5% vs. 83.3%, P=0.123) and duration of ECMO support (10.5 vs. 15.4 days, P=0.332) were not significantly different between the groups. However, the rate of bridging to cardiac replacement therapy, such as heart transplantation or left ventricular assist device, was significantly higher in the prophylactic LHD group (66.7%) than in the therapeutic LHD group (37.5%) (P=0.048).

Conclusions: Prophylactic percutaneous transseptal left atrial (LA) drainage at ECMO initiation appeared to be associated with a lower early mortality rate and a higher likelihood of successful bridging to cardiac replacement therapy than therapeutic LHD to treat complications of left ventricular distension.

Keywords: Cardiogenic shock (CS); extracorporeal membrane oxygenation; left heart decompression (LHD).

Conflict of interest statement

Conflicts of Interest: The authors have no conflicts of interest to declare.

2019 Journal of Thoracic Disease. All rights reserved.

Figures

Figure 1

Scheme of group distribution.

Figure 2

Percutaneous transseptal left atrial drainage. (A) Schematic diagram of percutaneous transseptal left atrial (LA) drainage. A 21–25-Fr single venous cannula with multiple side holes was inserted via the femoral vein. Through the opening of the interatrial septum created by atrial septostomy, the cannula was lying in the left atrium for biatrial decompression (red arrows: decompression of the left heart; blue arrows: decompression of the right heart). (B) Chest X-ray after transseptal left atrial drainage showing the position of a transseptal drainage cannula placed in the left atrium via the inferior vena cava and right atrium.

Figure 3

Outcomes of patients who received either prophylactic or therapeutic left heart decompression. (A) Rate of death in patients on extracorporeal membrane oxygenation (ECMO) support was not different between the therapeutic left heart decompression (LHD) group (blue bar) and prophylactic LHD group (red bar). The rate of bridging to heart transplantation or a left ventricular assist device was significantly higher in the prophylactic LHD group than in the therapeutic LHD group. (B) Early mortality was significantly higher in the therapeutic LHD group than in the prophylactic LHD group.