Commentary: The time for last-resort measures-be prepared.

Elisabeth Martin, MD, MPH, and Katsuhide Maeda, MD, PhD

AV groove disruption is a difficult situation that may result in uncontrollable bleeding and cardiogenic shock. Left ventricular decompression with VA ECMO should be considered in the management.

See Article page 213.

Over our entire career, practicing cardiothoracic surgeons will most definitely encounter some unexpected catastrophic complications. Atrioventricular groove disruption is one such catastrophic complication. This rupture is frequently associated with extensive decalcification of the mitral annulus, implantation of a large-sized prosthesis, cardiac manipulation, and advanced patient age. Currently, there is no consensus on the preferred surgical techniques for disruption repair, but intracardiac techniques appear to be the most commonly used surgical strategy. Various additional interventions have been described to improve the surgical outcomes, such as the use of intra-aortic balloon pump for afterload reduction or topical hemostatic agents. However, regardless of the repair strategy, postoperative hemostasis remains extremely difficult, and uncontrollable bleeding associated with cardiogenic shock may result in poor outcomes.

In this report, Salna and colleagues describe the innovative use of mechanical circulatory support with the use of a left ventricular apical drainage cannula. A central venoarterial extracorporeal membrane oxygenation (ECMO) system was designed to hasten myocardial recovery from the extended cardioplegic arrest and to achieve adequate ventricular decompression to reduce stress on the friable tissue and surgical repair. With this strategy, hemostasis improved significantly, and both patients survived to hospital discharge. In addition, left ventricular decompression was optimized to reduce blood stasis and associated risks of prosthesis thrombosis and development of intracardiac thrombus, which is a common finding in patients with severely depressed ejection fraction with akinetic or dyskinetic regional walls. Moreover, as mentioned by the authors, ECMO circuit anticoagulation will be held for a certain time period in patients with life-threatening coagulopathy and bleeding.

Various ventricular unloading techniques have been proposed in this etiology of cardiogenic shock, such as decompression cannula directly inserted through the left ventricular apex, venting via the pulmonary vein or the left atrial appendage, or ventricular decompression with the Impella system (Abiomed, Danvers, Mass) with a surgical transaortic approach or percutaneously with femoral or subclavian artery access. One may consider avoiding the additional surgical trauma to a struggling left ventricle (ie, manipulation associated with positioning the decompressing cannula through the ventricular apex), which could have a certain hypothetical benefit. Moreover, in patients with atrioventricular groove rupture, ventricular access via the mitral prosthesis is not recommended and handling of the friable cardiac mass and the fresh surgical repair could result in persistent massive bleeding.

A recent meta-analysis of observational studies showed that mortality was decreased in adults with cardiogenic shock treated with venoarterial ECMO combined with the use of a left ventricle decompression technique. The Impella device was under-represented in their study, but there was a trend toward improved survival and outcomes. A conceivable advantage from a percutaneous unloading device is the potential transition from central ECMO–Impella support to Impella support only. The trends in the use of this type of mechanical circulatory support are evolving, and it would be interesting to see its use broadened in a similar clinical scenario.

We want to congratulate the authors for this innovative technique, which resulted in successful outcomes following a catastrophic complication. We surgeons should always be prepared to manage difficult and unexpected situations.