Authors

• Dubravka Šipuš — University of Zagreb School of Medicine, Zagreb, Croatia — ORCID: 0000-0002-5631-0353
• Ivo Planinc — University of Zagreb School of Medicine, Zagreb, Croatia — ORCID: 0000-0003-0561-6704
• Boško Skorić — University of Zagreb School of Medicine, Zagreb, Croatia — ORCID: 0000-0001-5979-2346
• Vedran Velagić — University of Zagreb School of Medicine, Zagreb, Croatia — ORCID: 0000-0001-5425-5840
• Marijan Pašalić — University of Zagreb School of Medicine, Zagreb, Croatia — ORCID: 0000-0002-3197-2190
• Hrvoje Jurin — University of Zagreb School of Medicine, Zagreb, Croatia — ORCID: 0000-0002-2599-553X
• Daniel Lovrić — University of Zagreb School of Medicine, Zagreb, Croatia — ORCID: 0000-0002-5052-6559
• Jure Samardžić — University of Zagreb School of Medicine, Zagreb, Croatia — ORCID: 0000-0002-9346-6402
• Jana Ljubas Maček — University of Zagreb School of Medicine, Zagreb, Croatia — ORCID: 0000-0001-7171-2206
• Hrvoje Gašparović — University of Zagreb School of Medicine, Zagreb, Croatia — ORCID: 0000-0002-2492-3702
• Bojan Biočina — University of Zagreb School of Medicine, Zagreb, Croatia — ORCID: 0000-0003-3362-9596
• Davor Miličić — University of Zagreb School of Medicine, Zagreb, Croatia — ORCID: 0000-0001-9101-1570
• Maja Čikeš — University of Zagreb School of Medicine, Zagreb, Croatia — ORCID: 0000-0002-4772-5549

Abstract

**Background**: Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is widely used in refractory cardiogenic shock and cardiac arrest but is characterized by increased left ventricular (LV) afterload and consequent development of pulmonary oedema (ECMO lungs). The ProtekSoloTM (LivaNova, IT) cannula is inserted via the right femoral vein to the left atrium, by a trans-septal puncture (under the guidance of transesophageal echocardiography and fluoroscopy). This bypasses the LV by draining blood from the left atrium to a paracorporeal pump (eg Rotaflow pump (Maquet, DE)) and returning it via a femoral artery cannula, thus providing direct unloading of LV. (1-3) We aimed to demonstrate our experience with the paracorporeal LV assist device using the ProtekSolo cannula and Rotaflow pump (PSp-LVAD). **Patients and Methods**: 7 adult patients underwent PSp-LVAD placement in UHC Zagreb from January to December 2020. We divided the patients in two groups: those who required PSp-LVAD to treat ECMO lungs (n=4) and those who received PSp-LVAD implantation prior to developing ECMO lungs (n=3). In addition to the description of the treated patients, we also assessed 30-day all-cause mortality. **Results**: The baseline characteristics of patients are shown in **Table 1**. All patients were male, mean age 56±9.3 years. 57.1% of patients underwent PSp-LVAD placement due to worsening of chronic heart failure and 42.9% due to acute coronary syndrome. Concurrent infection was present in 57.1% of patients. 71.4% were first on VA-ECMO support, of those 80% developed ECMO lungs. Laboratory tests (**Figure 1**) show improvement in kidney and liver function after PSp-LVAD placement. Outcomes are shown in **Table 2**; patients in prophylactic group have lower observed 30-day mortality rate (33% vs 75%) and longer VA-ECMO support duration due to lower mortality. Besides 2 patients who are still in active treatment, all others died during initial hospitalization due to infective complications, predominantly those that had a concurrent infection upon institution of the PSp-LVAD. ### TABLE 1: Baseline characteristics. | **N** | **7** | **N** | **7** | | --- | --- | --- | --- | | **Mean age (years)** | 56±9.3 | **Heart rate (beats/min)** | 90 (85-125) | | **Sex (male %)** | 7 (100%) | **Urinary output hourly (ml/h)** | 100 (15-180) | | **Mean BMI (kg/m2)** | 25.5±2.9 | **Laboratory values** | | | **Aetiology of cardiogenic shock** | | Lactate (mmol/L) | 2.1 (0.4-4.8) | | Worsening of chronic heart failure | 4 (57.1%) | BUN (mmol/L) | 11.5 (1.9-19.7) | | Acute coronary syndrome | 3 (42.9%) | Creatinine (umol/L) | 91 (61-133) | | **Duration of disease** | | AST (IU/L) | 193 (19-2132) | | Cardiomyopathy (years) | 8±5.3 | ALT (IU/L) | 75 (17-566) | | Acute coronary syndrome (days) | 5±6 | NTproBNP (ng/L) | 8118 (41-26245) | | **SAVE score** | -3 (-13, 6) | **Inotropic or vasopressor therapy before PSp-LVAD placement** | | | **VA-ECMO prior to PSp-LVAD** | 5 (71.4%) | Dobutamine | 4 (57.1%) | | **ECMO lungs** | 4 (57.1%) | Milrinone | 3 (42.9%) | | **Infection prior to VA-ECMO** | 4 (57.1%) | Levosimendan | 4 (57.1%) | | **Mean arterial pressure (mmHg)** | 76 (60-79) | Norepinephrine | 5 (71.4%) | [†] BMI: body mass index, SAVE: Survival After Veno-arterial Ecmo, VA-ECMO: veno-arterial extra corporeal membrane oxygenation, PSp-LVAD: Protek Solo paracorporeal left ventricular assist device, BUN: blood urea nitrogen, AST: aspartate transaminase, ALT alanine transaminase, NTproBNP: N-terminal prohormone of brain natriuretic peptide. FIGURE 1. Laboratory values before and after Protek Solo paracorporeal left ventricular assist device placement. BUN: blood urea nitrogen, NTproBNP: N-terminal prohormone of brain natriuretic peptide, AST: aspartate transaminase. ### TABLE 2: Outcomes. | | **ECMO lungs before PSp-LVAD (N=4)** | **No ECMO lungs before PSp-LVAD (N=3)** | | --- | --- | --- | | **30-day mortality** | 3 (75%) | 1 (33%) | | **Survival to decannulation** | 1 (25%) | 1 (33%) | | **Mean PSp-LVAD days** | 11±5 | 32.5±12 | | **VA-ECMO prior to PSp-LVAD** | 4 (100%) | 1 (33%) | | **Removal of oxygenator** | 2 (50%) | 3 (100%) | | **Durable LVAD implantation** | 0 (0%) | 1 (33%) | | **Complications** | | | | Infective | 4 (100%) | 1 (33%) | | Bleeding | 2 (50%) | 1 (33%) | [†] VA-ECMO: veno-arterial extra corporeal membrane oxygenation, PSp-LVAD: Protek Solo paracorporeal left ventricular assist device, LVAD: left ventricular assist device. **Conclusion**: Pulmonary edema (ECMO lungs) due to increased LV afterload is a major complication of VA-ECMO. Prophylactic LV unloading by PSp-LVAD seems associated with lower 30-days mortality.

Keywords

cardiogenic shock, extracorporeal membrane oxygenation, ProtekSolo, left ventricular unloading

DOI

Literature

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