P38: Minimally Invasive Extracorporeal Membrane Oxygenation? Concomitant Right and Left Ventricle Assist Devices via Jugular, Subclavian, and Carotid Approaches Reduce Pressor Requirements and Lactic Acid in Cardiogenic Shock Patients, A Follow-Up Observational Study on the “Pro-Pella” Approach.

Purpose of Study: Patients presenting with acute biventricular failure suffer high mortality rates even with optimal treatment. Recent developments in surgically inserted right and left ventricular support devices have made these minimally invasive options an effective form of mechanical circulatory support. Treatment of acute cardiogenic shock and biventricular failure using this technique is poorly studied. Here we present a follow-up to our early experience with this technique. Methods Used: A retrospective review of a prospectively collected database was performed for all patients receiving surgical biventricular support from March 2018 to December 2020. Inclusion criteria were for adult patients suffering acute biventricular failure that received concomitant surgical biventricular support. A right ventricular support device (RVAD) inserted in the right internal jugular vein combined with a left ventricular support device (LVAD) inserted in the right subclavian artery or carotid artery provided support. Primary endpoint was patient survival to device explant. Secondary endpoints were change in vasoactive inotrope Score (VIS) and normalization of lactic acid. Patient characteristics, pre and post-operative variables, and short-term outcomes were collected with a focus on patient hemodynamics and device-related complications. Results: Fourteen patients (complete data for 11) met inclusion criteria aged 20-70 (median 59). The etiologies of heart failure included both ischemic (63%) and nonischemic cardiomyopathies (37%) RVAD support was via the right internal jugular vein. One patient received LVAD support through the carotid artery, while the others were via the subclavian artery. Median preoperative cardiac index was 1.7L/min/m2, Interquartile range (IQR) 1.5-2.5,L/min/m2, with median cardiac output of 3.87 L/min, IQR (3.03-5.94 L/min). Left ventricular ejection fraction ranged 10%-46% on inotropic support, with a median preoperative vasoactive inotrope score (VIS) of 28, IQR (23.5-33.06) Patients had a median immediate postoperative reduction in VIS score of 26.19, IQR (14-32) at 24 hours. (Figure 1) after device implantation. Fifty percent of patients normalized lactic acid levels within 24 hours. All patients surviving to 24 hours post-op had a reduction in lactic acid levels. Eight patients survived to discharge and all but one of these patients remained alive at 1-year post-discharge follow-up. There were no device related strokes, pulmonary emboli, or valvular injuries. Summary: Combined surgical RVAD and LVAD implantation continue to provide effective treatment and adequate hemodynamic support as a bridge to further treatment in patients with biventricular failure and cardiogenic shock. This specific technique warrants further investigation and comparison to current treatments. It offers a minimally invasive alternative to VA ECMO.