Percutaneous Right Internal Jugular And Right Subclavian Arterial Biventricular Support In The Management Of Adult Cardiogenic Shock
Richard W. Walsh1, Michael T. Cain2, Bernice Badu1, Courtney Goulet1, Lucian A. Durham, III3, Lyle D. Joyce3, Asim Mohammed4, David L. Joyce3.
1Medical College of Wisconsin, Milwaukee, WI, USA, 2Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA, 3Department of Surgery, Division of Cardiothoracic Surgery, Medical College of Wisconsin, Milwaukee, WI, USA, 4Department of Cardiology, Medical College of Wisconsin, Milwaukee, WI, USA
BACKGROUND: Acute biventricular failure poses a unique challenge due to the morbidity associated with conventional support techniques, such as venoarterial extracorporeal membrane oxygenation (VA ECMO). Recent developments in percutaneously inserted right and left ventricular support devices have made these minimally invasive options useful in acute failure. Biventricular percutaneous support in the adult population for treatment of acute cardiogenic shock not been reported. Here we present our early experience with this technique. METHODS: A retrospective review of a prospectively collected database was performed for all patients receiving biventricular percutaneous support from March 2018 to December 2018. Inclusion criteria were for patients suffering acute cardiogenic shock and that received concomitant percutaneous biventricular support. This support was provided via 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. Primary endpoint was patient survival to device explant. Patient characteristics, pre and post-operative variables, and short-term outcomes were collected with a focus on patient hemodynamics and device related complications. RESULTS: 4 patients met inclusion criteria age 20-75 (median 59). Etiologies of heart failure included viral cardiomyopathy (n=1), acute Ischemic heart disease (n=2), and post cardiotomy biventricular failure (n=1). Median preoperative cardiac index was 1.8L/min/m2 (ranged 1.5-2.6), with median cardiac output of 3.8 L/min (2.9-6.7) . Ejection fraction was 5%-60% on inotropic support, with a median preoperative vasoactive inotrope score (VIS) of 32.1 (18-43.8). Patients normalized their preoperative lactic acidosis after a median of 3 hours and were noted to have a median immediate postoperative reduction in VIS score of 12.2 (1-23.1, Figure 1) after device implantation. Patients received biventricular support for 5.5 days (range 1-11). Two patients survived to device explant, with no patient suffering device related stroke, pulmonary emboli, valvular injury, or bleeding requiring reintervention. 
CONCLUSIONS: Combined percutaneous RVAD and LVAD implantation can successfully be employed as a stand-alone therapy, or as a bridge to further treatment in patients with cardiogenic shock. This novel technique warrants further investigation and refinement, and can potentially offer a rapidly deployed minimally invasive alternative to VA ECMO in select patients.
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