Novel minimally invasive surgical approach using an external ventricular assist device and extracorporeal membrane oxygenation in refractory cardiogenic shock

OBJECTIVES: The use of short-term mechanical circulatory support (MCS) has increased in the treatment of refractory cardiogenic shock (RCS). Percutaneous short-term MCS technology has emerged rapidly; however, limitations in flow and durability remain. We therefore investigated a minimally invasive surgical approach using an external ventricular assist device (VAD)and extracorporeal membrane oxygenation (ECMO) in patients with RCS. METHODS: Twenty-five patients underwent minimally invasive external VAD insertion with a magnetically levitated centrifugal pump for various causes of cardiogenic shock between April 2010 and May 2016. An external VAD was established with left ventricular apical cannulation through a minithoracotomy and right or left axillary artery cannulation. In patients with biventricular failure or pulmonary complications, femoral venous cannulation was added as an additional inflow source, and ECMO was spliced into the external VAD circuit. RESULTS: Mean patient age was 58 +/- 9.1 and 80% were men. All patients were in Interagency Registry for Mechanically Assisted Circulatory Support profile I RCS. The aetiology of RCS was decompensated chronic heart failure in 13 (52%), and acute myocardial infarction in 12 (48%). Twenty-three (92%) received percutaneous short-term MCS prior to surgery. The procedure was performed without cardiopulmonary bypass in all patients. ECMO was added in 17 patients (68%) and explanted after a median of 4 days of support. The average flow obtained was 5.3 +/- 1.1 l/min. The median duration of external VAD support was 22 days. Major complications during support included bleeding events in seven (28%) and cerebrovascular events in four (16%). The in-hospital mortality rate was 32%. Seventeen patients (68%) survived to the next destination including myocardial recovery in three (12%), device exchange to a durable VAD in 12 (48%) and heart transplantation in two (8%). The Kaplan-Meier survival rates at 6 months and 1 year were 92% and 77%, respectively. CONCLUSIONS: Our minimally invasive surgical approach using an external VAD is a feasible strategy for patients with cardiogenic shock who are refractory to percutaneous short-term MCS support.