Transapical Cannulation With a Dual Lumen Cannula for Mechanical Circulatory Support in Cardiogenic Shock : ASAIO Journal

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Transapical Cannulation With a Dual Lumen Cannula for Mechanical Circulatory Support in Cardiogenic Shock

Singh, Ramesh*; Chandel, Abhimanyu; Paras, Jen; Lee, Thomas Brad; Tang, Daniel G.*; Shah, Palak§; Desai, Mehul

Author Information
doi: 10.1097/MAT.0000000000001683
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Abstract

The use of temporary mechanical support to restore systemic perfusion in cardiogenic shock has substantially increased in the last 2 decades.1 The development of percutaneous left ventricular assist devices has allowed for cardiac support of 2 to 5.5 L/min of flow.2 However, in profound shock these devices may not provide adequate circulatory support, may be limited by vascular access, can result in clinically significant hemolysis, and can limit patient mobility. Percutaneous peripheral veno-arterial extracorporeal membrane oxygenation (VA-ECMO) can provide adequate systemic perfusion; although the commonly employed femoro-femoral VA-ECMO can significantly restrict patient mobility and prolong recovery. All peripheral modalities of VA-ECMO result in the presence of a retrograde jet which can significantly increase left ventricular afterload leading to increased left ventricular end-diastolic pressure, increased myocardial oxygen demand, pulmonary edema, and impair myocardial recovery.3 Furthermore, retrograde perfusion of the aorta increases the risk of aortic dissection during cannulation, cerebral embolization, and malperfusion of aortic branch vessels.4

An alternative method of cardiopulmonary bypass employed through aortic cannulation via the apex of the left ventricle and aortic valve has been utilized successfully in the intraoperative setting during coronary bypass surgery in the presence of significant calcific disease of the ascending aorta and in the management of type-A aortic dissections.5,6 A similar technique for left ventricular support as a bridge to clinical decision utilizing the transapical cannulation for patients with cardiogenic shock has been described.7,8 We present a description of our surgical technique and our institution’s experience with the use of transapical left ventricular cannulation with a dual lumen cannula for left ventricle support in the management of cardiogenic shock as a bridge to myocardial recovery or definitive decision.

Materials and Methods

Study Population

We performed a retrospective analysis of all patients >18 years of age who underwent apical cannulation for cardiogenic shock between November 1, 2019, and March 1, 2021, at Inova Fairfax Hospital in Falls Church, VA, a tertiary care referral center. The study was approved by the Institutional Review Board (#18-832) at Inova Fairfax Hospital. Preprocedure data including demographics, comorbid diseases, indication for mechanical circulatory support, cardiogenic shock severity, and right heart catheterization data before support device implantation were collected. Clinical outcomes following apical cannulation that were evaluated include successful ventilator weaning (defined as tracheal extubation or tolerance of spontaneous ventilation through tracheostomy without positive pressure), duration of support via the apical cannula, and ultimate outcome of cardiogenic shock after temporary support (recovery, durable left ventricular assist device, cardiac transplantation, or death). Clinical data of intravascular hemolysis and hemodynamics before and after insertion of left ventricular support device were collected where available within 24 hours of the procedure. Quantification of aortic insufficiency was based on finalized radiographic interpretation of formal echocardiography. Categorical variables are presented as counts with proportions and continuous variables are presented as median with the interquartile range.

General Management Protocol

Transapical cannulation was considered in all patients with cardiogenic shock that required isolated left ventricular support or required left ventricular support in conjunction with a right ventricular support device. Patients deemed ineligible for other left ventricular support strategies due to vascular anatomic limitations, such as small vessel size, were considered for this technique. Alternatively, those with comorbidities including prior cardiac surgery involving the apex of the heart, severe aortic insufficiency, or apical thrombosis were not considered suitable candidates for this therapy.

Standard left ventricular apical cannulation technique

Under transesophageal and transthoracic ultrasound guidance, the apex of the heart is identified (typically laterally displaced in patients with chronic heart failure). If the patient is not already on mechanical ventilation, endotracheal intubation is performed with the use of a single lumen endotracheal tube. A bump is placed under the left scapula and the arm is tucked with a loose bend in the elbow. Defibrillation pads are placed given the potential for the induction of malignant arrhythmias during the cannulation procedure. An anterior thoracotomy is then performed and the rib spaces are gently spread. The pericardial fat is then excised and the pericardium is opened over the apex of the heart. Again under transesophageal guidance, a location on the heart is selected, with consideration of site selection ensuring a direct route towards the aortic valve and that could also be utilized for a future left ventricular assist device (LVAD) inflow cannula site should the need arise. A 14-mm Dacron graft is sewn to the heart at this location with pledgeted 4-0 polypropelene sutures for stability and hemostasis. A Dacron graft is utilized over other techniques as it is critical for the cannula to be completely secure as patients are typically encouraged to ambulate postoperatively. A 32F chest tube is brought out inferior and laterally from the thoracotomy site in a subfascial tunnel. Under transesophageal ultrasound and fluoroscopic guidance, a needle is inserted into the apex of the left ventricle inside the 14-mm Dacron graft. A Bentson wire is then passed until it is seen going out the aortic valve into the aortic arch. An exchange catheter is then used to exchange the Bentson wire for an Amplatz stiff wire. The wire is then passed through the previously placed 32F chest tube. Heparin is administered for a goal activated clotting time of over 250 seconds. Under real-time fluoroscopic and transesophageal ultrasound guidance, the 31F Protek Duo RD cannula is inserted via a modified Seldinger technique. Predilation is typically not required. It is important to ensure that the wire does not buckle and that the cannula is inserted deep enough that the aortic valve is situated between the outflow and inflow channels of the cannula, while ensuring that all the inflow channels remain in the left ventricle (Figure 1).

F1
Figure 1.:
Appropriate dual lumen catheter positioning. Chest radiograph (A) and echocardiography (B, C) demonstrating appropriate positioning of the Protek Duo RD dual lumen catheter (red arrow) entering the cardiac apex and extending through the left ventricle (LV) and aortic valve before entering the aortic arch. All three inflow channels (blue arrows) are noted within the LV (C).

The cannula is then connected to the temporary extracorporeal pump of choice (CentriMag device [Abbott Laboratories, Abbott Park, IL] per institutional preference) and flow is commenced. The cannula is secured to the 14-mm Dacron graft with heavy silk ties. Since the cannula was tunneled subfascially through a separate stab incision, the thoracotomy incision can be closed completely and the cannula secured again externally with multiple 0 Silk sutures.

Once in place, typically, systemic anticoagulation is administered per standard institutional mechanical circulatory support protocol with heparin titrated to antifactor Xa range of 0.3 to 0.5 IU/mL. However, systemic anticoagulation is administered at the discretion of the patient’s provider and can be adjusted based on the patient’s clinical status.

Results

A total of 9 patients were identified during the study period that underwent transapical cannulation with a dual lumen cannula for left ventricular support for the temporary management of cardiogenic shock. The baseline characteristics and comorbid considerations of patients is provided in Table 1. The median age was 58 years (range: 19–73) and most patients were male (77.8%). Before mechanical support through the transapical cannula, patients had a median cardiac index of 1.7 (interquartile range: 1.4–2.0) and a median pulmonary capillary wedge pressure of 31 (26–33.5). Most patients identified for this support strategy displayed Society of Cardiovascular Angiography class D cardiogenic shock (N = 6). The majority (N = 5) of patients that underwent transapical cannulation required temporary support for cardiogenic shock related to an acute exacerbation of chronic heart failure. Three patients were being managed for shock related to acute myocardial ischemia and one patient required support for acute viral myocarditis. Of the patients that underwent this procedure, four patients were already supported by a percutaneous MCS device, but were upgraded due to a requirement for higher flows.

Table 1. - Baseline Characteristics and Comorbidities of the Study Group
Demographics
Age (y) 58 (57–66)
Gender, women 2 (22.2)
Chronic heart failure 5 (55.6)
Peripheral vascular disease 0
Chronic kidney disease 3 (33.3)
Diabetes 7 (77.8)
Right heart catheterization
 RAP (mmHg) 16.5 (12–17.5)
 mPAP (mmHg) 38.8 (36.2–40.5)
 PCWP (mmHg) 31 (26––33.5)
 PAPi 1.8 (1.2–3.0)
 CPO (W) 0.60 (0.49–0.68)
 Fick CI 1.7 (1.4–2.0)
Cardiac support indication and considerations
 SCAI shock classification C 3 (33.3)
 SCAI shock classification D 6 (66.6)
 Best perioperative mortality predictor score 7 (4–7)
 Acute coronary syndrome 3 (33.3)
 Acute non-ischemic cardiomyopathy 1 (11.1)
 Presence of other MCS device 4 (44.4)
 IABP 0 (0)
 Impella 4 (44.4)
Data presented as median (25th percentile–75th percentile) or n (%).
CI, cardiac index; CPO, cardiac power output; IABP, intra-aortic balloon pump; MCS, mechanical circulatory support; mPAP, mean pulmonary artery pressure; PAPi, pulmonary artery pulsatility index; PCWP, pulmonary capillary wedge pressure; RAP, right atrial pressure; SCAI, society for cardiovascular angiography and interventions.

Following transapical cannulation, clinical outcomes of the nine patients are displayed in Table 2. The majority (N = 7) of patients were weaned from mechanical ventilation with a median time to ventilator liberation of 1 day (interquartile range: 0–1). For the 7 patients ultimately decannulated, the median duration of mechanical circulatory support via the transapical cannula was 9 days (range: 1–19 days). A minority of the cohort died during hospitalization (N = 3, 33.3%) with all deaths attributed to progressive shock and multiorgan dysfunction not reversed with mechanical circulatory support. The majority (N = 6, 55.6%) ultimately either achieved cardiac recovery (N = 1), had a durable LVAD implanted (N = 1), or underwent cardiac transplantation (N = 4).

Table 2. - Outcomes for the Study Group
Clinical Outcomes
Weaned from ventilator 7 (77.8)
Time from cannulation to ventilator weaning (d) 1 (0–1)
Time spent with apical cannula (d) 9 (3–15)
Cardiac recovery 1 (11.1)
Left ventricular assist device implanted 1 (11.1)
Cardiac transplant 4 (44.4)
Death during hospitalization 3 (33.3)
Data presented as median (25th percentile–75th percentile) or n (%).

Lactate dehydrogenase as a marker of intravascular hemolysis was compared in patients both before and after transapical cannulation (Table 3). Lactate dehydrogenase magnitude increased in only one patient, which clinically, was attributed to cardiogenic shock and related severe hepatic dysfunction. Plasma free hemoglobin concentration after left ventricular cannulation was available for only three patients and was not elevated above the reference range of the test in these instances. Additionally, hemodynamic measurements were recorded for patients before and after apical cannulation (Table 3). Median mixed venous saturation, serum lactate, cardiac power output, and cardiac index all improved following the apical cannulation. Finally, patient specific factors including precannulation left ventricular dimensions, aortic insufficiency encountered during and after catheter removal, maximum flow rate, and individual clinical outcomes are displayed in Table 4. Significantly, the median maximum flow rate delivered by the apical cannula was 4.9 L/min and none of the patients successfully decannulated developed new aortic insufficiency.

Table 3. - Precannulation and Postcannulation Hemodynamics
Patient Precannulation Postcannulation
LDH (U/L) SvO2 (%) Lactate (mmol/L) CPO (W) CI (L/min/m2) LDH (U/L) SvO2 (%) Lactate (mmol/L) CPO (W) CI (L/min/m2)
1 430 53 1.3 0.40 1.3 356 54 1.0 1.15 3.4
2 831 42 5.9 0.58 1.2 580 74 0.9 0.78 2.8
3 - - 1.5 0.51 1.4 428 43 2.5 0.63 1.8
4 446 59 1.6 0.67 2.5 371 55 1.5 0.81 2.2
5 1998 52 1.8 0.47 1.6 1351 72 1.1 0.91 2.9
6 649 - 3.1 - - 451 44 2.5 0.61 1.9
7 558 48 1.6 0.69 1.7 446 61 1.8 0.87 3.1
8 681 53 1.4 0.61 1.7 4550 48 5.2 0.54 1.8
9 - 58 1.3 0.99 2.2 317 59 0.8 1.23 2.5
Median 649 53 1.6 0.60 1.7 446 55 1.5 0.81 2.5
-, missing data; CI, cardiac index; CPO, cardiac power output; LDH, lactate dehydrogenase; SvO2, mixed venous oxygen saturation.

Table 4. - Anatomic and Flow Considerations of the Transapical Cannulation Technique
Patient Precannulation During Support Following Support Removal
LV Size (cm) AI AI Maximum Flow Achieved (L/min) AI* Overall Outcome
1 8.7 None Moderate 6.0 None Transplant
2 - None Moderate 4.7 None Transplant
3 Normal None None - None Bridge to recovery
4 7.4 None None 3.3 None LVAD
5 8.2 None Trace 4.2 None Transplant
6 Dilated None Mild 4.0 - Deceased (care withdrawn by family)
7 4.2 Mild None 5.1 None Transplant
8 6.8 Mild None 5.0 - Deceased (cardiogenic shock)
9 7.3 Trace Trace 6.3 Trace Deceased (cardiogenic shock)
-, missing data; AI, aortic insufficiency; LV, left ventricle; LVAD, left ventricular assist device.
*Missing data is due to patient death before removal of apical cannula.

Discussion

We describe our institution’s clinical experience with the use of transapical left ventricular cannulation with a dual lumen cannula for left ventricular support in the management of cardiogenic shock as a bridge to recovery or definitive decision. Our case series is the largest description of the use of this technique to date and documents the promising outcomes of the application of the single-site direct access strategy. Overall, 66% of patients survived to a durable LVAD, cardiac transplantation, or achieved myocardial recovery with mechanical unloading. This method of temporary support was notable for the rapid time to mechanical ventilation liberation and related mobility and rehabilitation achieved in a number of patients (Figure 2). Additionally, we found this technique was associated with limited intravascular hemolysis, excellent flow rates, and improved hemodynamic measurements. Aortic insufficiency, although a theoretical concern, was not a significant issue experienced by patients in our cohort that achieved device explantation.

F2
Figure 2.:
A patient ambulating with the medical team’s assistance shortly after apical dual lumen cannulation and initiation of mechanical circulatory support via the Centrimag pump.

The technique of off-pump insertion of a single dual lumen cannula in the left ventricle represents an alternative management option in patients with vasculature not amenable to axillary, innominate, or femoral cannulation. This technique can provide full systemic support while eliminating the effects of high afterload, minimizing intravascular hemolysis, facilitating early liberation from mechanical ventilation, and improving patient mobility after the procedure. While descriptions of this technique are available, its application and use in clinical practice has largely been confined to case reports of exceptional patient circumstances where other modes of support have been deemed unsuitable.9 Left ventricular cannulation via the method described allowed for full systemic support in patients with cardiogenic shock with the use of an extracorporeal magnetically levitated centrifugal pump. For patients with pulmonary dysfunction, an oxygenator could easily be added to this circuit and further, for patients with biventricular failure, a second dual lumen cannula could be inserted into the right ventricle via the right internal jugular vein and attached to an additional pump to provide biventricular support. Significantly, no serious complications such as embolic stroke, extremity malperfusion, cannula dislodgment, cardiac tamponade, air embolism, or surgical site infection occurred in this small case series.

Expanded use of this method of temporary extracorporeal support represents a novel and potentially advantageous option that could minimize the impact of retrograde perfusion of the aorta, bleeding, intravascular hemolysis leading to renal failure, vascular access site complications, and delayed mobility that hinder other more commonly employed temporary mechanical circulatory support methods. Furthermore, this technique avoids the need for reperfusion cannulas which may also minimizes the long-term complications of deconditioning and limb ischemia. Given that an oxygenator is not required and low hemolysis rates have been described with centrifugal pumps, this method may also mitigate complications classically seen if anticoagulation must be held observed with the use of other means of mechanical circulatory support.10 Relatedly, at our institution, systemic anticoagulation for patients supported with this method has not been considered mandatory and, unlike patients receiving ECMO or percutaneous mechanical circulatory support, is left at the discretion of the treating provider.

Despite these promising results, unanswered questions remain that are well suited to future study in larger cohorts. For instance, although all patients in this series experienced a numeric improvement in cardiac index after left ventricular cannulation, in several patients the magnitude of improvement in cardiac function was small. Potentially, this finding could be related, in part, to the nonuniform timing of hemodynamic measurements given the retrospective nature of this analysis or to static measures of cardiac function in a dynamic clinical condition. Regardless, future study is critical to evaluate if anatomic or technical factors can be identified and optimized to ensure necessary cardiac augmentation in all patients this technique is employed in. Further study will also be important to identify and minimize adverse events related to this technique and to define the best suited support modality to optimize clinical outcomes for the various presentations of cardiogenic shock. Our center plans to continue to utilize this method in appropriate clinical scenarios, especially when other cannulation techniques are not technically feasible or otherwise not desired.

References

1. Shah M, Patnaik S, Patel B, et al.: Trends in mechanical circulatory support use and hospital mortality among patients with acute myocardial infarction and non-infarction related cardiogenic shock in the United States. Clin Res Cardiol. 107: 287–303, 2018.
2. Telukuntla KS, Estep JD: Acute mechanical circulatory support for cardiogenic shock. Methodist Debakey Cardiovasc J. 16: 27–35, 2020.
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4. Combes A, Price S, Slutsky AS, Brodie D: Temporary circulatory support for cardiogenic shock. Lancet. 396: 199–212, 2020.
5. Wada S, Yamamoto S, Honda J, Hiramoto A, Wada H, Hosoda Y: Transapical aortic cannulation for cardiopulmonary bypass in type A aortic dissection operations. J Thorac Cardiovasc Surg. 132: 369–372, 2006.
6. Sosnowski AW, Jutley RS, Masala N, Alexiou C, Swanevelder J: How I do it: Transapical cannulation for acute type-A aortic dissection. J Cardiothorac Surg. 3: 4, 2008.
7. Khalpey Z, Smith R, Echeverria A, le Tran P, Kazui T: A novel minimally invasive off-pump biventricular assist device insertion technique. J Thorac Cardiovasc Surg. 151: e5–e7, 2016.
8. Rao P, Alouidor B, Smith R, Khalpey Z: Ambulatory central VA-ECMO with biventricular decompression for acute cardiogenic shock. Catheter Cardiovasc Interv. 92: 1002–1004, 2018.
9. Belani K, Saikus CE, Schroder JN, Klinger RY: Transapical ProtekDuo rapid deployment cannula as temporary left ventricular assist device in a Jehovah’s witness patient. J Cardiothorac Vasc Anesth. 35: 3735–3742, 2021.
10. Chan CH, Pieper IL, Hambly R, et al.: The CentriMag centrifugal blood pump as a benchmark for in vitro testing of hemocompatibility in implantable ventricular assist devices. Artif Organs. 39: 93–101, 2015.
Keywords:

cardiogenic shock; transapical cannulation; temporary circulatory support; mechanical circulatory support; heart failure

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