Schaefer Anne-Kristin, Wiedemann Dominik, Heinz Gottfried, Riebandt Julia, Zilberszac Robert
Department of Cardiac and Thoracic Aortic Surgery, Medical University of Vienna, Vienna, Austria.
Department of Cardiac Surgery, Karl Landsteiner University, University Clinic St. Pölten, St. Pölten, Austria.
J Cardiothorac Surg. 2025 Jan 10;20(1):57. doi: 10.1186/s13019-024-03288-4.
Left ventricular unloading is needed in patients on extracorporeal life support (ECLS) with severely impaired left ventricular contractility to avoid stasis and pulmonary congestion, and to promote LV recovery. The presence of thrombi in the LV precludes the use of conventional active unloading methods such as transaortic microaxial pumps or apical LV vents. We describe placement of a vent cannula via the left atrial appendage (LAA) as a useful bailout option.
A 61-year-old patient presenting with normotensive cardiogenic shock (SCAI C) after subacute anterior wall myocardial infarction deteriorated with pulmonary edema and ventricular fibrillation, requiring veno-arterial extracorporeal life support under ongoing CPR (SCAI E). An Impella CP was placed for LV unloading, but was unable to generate flow and was thus removed. A large left ventricular thrombus was detected as the cause for insufficient Impella flow. For urgent LV unloading, we placed a vent cannula via the LAA through a thoracotomy to bridge our patient to total artificial heart implantation. However, intraoperative TEE showed resolution of the LV thrombus, enabling to change the strategy to left ventricular assist device implantation only, which was performed successfully. Our patient made a full recovery and is now doing well in regular outpatient follow ups.
ECLS provides excellent circulatory support at the price of a high complication burden and considerable LV afterload increase. ECLS complications often require individualized solutions not represented in current heart failure guidelines. This patient has developed a dreaded and nearly always fatal ECLS complication, which was successfully managed with vent placement via the LAA.
对于体外生命支持（ECLS）且左心室收缩功能严重受损的患者，需要进行左心室减负，以避免血液淤滞和肺充血，并促进左心室恢复。左心室内存在血栓会妨碍使用传统的主动减负方法，如经主动脉微轴泵或左心室心尖引流管。我们描述了一种通过左心耳（LAA）放置引流管作为一种有用的补救选择。
一名61岁患者在亚急性前壁心肌梗死后出现血压正常的心源性休克（SCAI C），随后因肺水肿和心室颤动病情恶化，在持续心肺复苏（SCAI E）下需要进行静脉-动脉体外生命支持。放置了一台Impella CP用于左心室减负，但无法产生血流，因此将其移除。检测到一个大的左心室血栓是Impella血流不足的原因。为了紧急进行左心室减负，我们通过开胸手术经左心耳放置了一根引流管，以使患者过渡到全人工心脏植入。然而，术中经食管超声心动图显示左心室血栓溶解，从而能够将策略改为仅植入左心室辅助装置，并成功实施。我们的患者完全康复，目前在定期门诊随访中情况良好。
ECLS以高并发症负担和左心室后负荷显著增加为代价提供了出色的循环支持。ECLS并发症往往需要个体化解决方案，而目前的心力衰竭指南中并未涵盖。该患者发生了一种可怕且几乎总是致命的ECLS并发症，通过经左心耳放置引流管成功进行了处理。
