a 26-year - old female patient was transferred to the samsung medical center from an outside institution due to severe refractory cardiogenic shock .
the patient was diagnosed with non - hodgkin s lymphoma 2 years prior and underwent 6 cycles of chemotherapy , which included doxorubicin .
after chemotherapy treatments were completed , the patient suffered from orthopnea and dyspnea , and an echocardiography revealed a severely depressed left ventricular ( lv ) ejection fraction ( 25% ) and dilated lv . due to complications from cancer treatments , she had an episode of acute decompensated heart failure and was referred to samsung medical center . on initial presentation ,
vital signs included arterial blood pressure of 79/27 mmhg , heart rate of 133 beats / min , respiratory rate of 28 breaths / min , and body temperature of 35.9c .
she had pulmonary edema with bilateral pulmonary congestion ( fig . 1 ) and multiorgan failure with liver and kidney involvement . despite the use of inotropes and vasopressors , we were unable to achieve stable vital signs .
percutaneous extracorporeal life support ( p - ecls ) was then placed using the left femoral artery and vein .
however , the left leg became ischemic after several hours , and we decided to shift the cannulas to the right groin .
the patient was brought to a hybrid operating room , and the groin was opened bilaterally .
then , the arterial and venous cannulas were inserted through the common femoral artery and vein , and the catheter for the superficial femoral artery was inserted at the same time . the following day ,
transthoracic echocardiography revealed a distended left ventricle , and the chest x - ray showed worsening pulmonary edema . in this case , we determined that an atrial septostomy was not a viable option since both the femoral veins were already cannulated or had been surgically repaired .
instead , we performed an emergency standard median sternotomy and inserted a vent catheter ( malleable 20 fr . ) with a tip - cut into the right upper pulmonary vein and passed it into the left ventricle .
then , the inserted vent catheter was connected to the venous line of the p - ecls circuit via a y - shaped connector ( fig .
, the pump flow was maintained at 2.4 l / min / m , obtaining a mean systemic pressure of 60 mmhg and central venous pressure of 8 mmhg .
the flow through the vent catheter was measured to be 1 to 2 l / min .
the patient was on p - ecls and left heart venting for 5 days . during this time ,
3 ) . transthoracic echocardiography revealed improved right and lv function and decreased chamber size .
when the function of the right heart and the lung improved , the drainage from the femoral vein was gradually reduced by progressively clamping the venous line and lowering the r.p.m . in this way , the system was modified from p - ecls to paracorporeal lv assist device ( lvad ) by the complete clamping of the femoral venous drainage catheter .
thus , the femoral venous cannula and the oxygenator were removed on postoperative day 5 .
the reasons for our decision were complete lv support , possible longer - term support due to the absence of the oxygenator and the low level of anticoagulation , and the prevention of recurrent lv distension . on postoperative day 8 , we were able to wean the patient from lvad and remove all cannulas from her chest and groin .
she was extubated and was finally discharged home on hospital day 28 . during follow - up ,
the lv ejection fraction worsened from 40% to 20% , and the symptoms of dyspnea became worse than before hospital discharge .
currently , this patient is on the heart transplant list and is waiting for transplantation .
however , due to its inability to directly drain the left heart , its effectiveness in assisting the heart is limited .
additionally , several factors including severely reduced lv function , blood from native pulmonary and bronchial circulation , and increased afterload due to retrograde perfusion from the arterial cannula may lead to lv distension .
this resultant lv distension can cause pulmonary edema , pulmonary hemorrhage , and myocardial ischemia .
although paracorporeal lvad placed through a median sternotomy provide better hemodynamic support without the risk of lv distension , complications of central cannulation such as bleeding and infection limit the widespread use of this technique .
we report a case in which trans - sternal lv drainage was utilized while the patient was receiving p - ecls that was followed by a subsequent switch to paracorporeal lvad without further surgery .
this strategy allowed the transformation of peripheral circulatory support into effective myocardial and systemic circulatory assistance and minimized the surgical risk .
although p - ecls offers excellent support to the blood circulation , its effect on the heart is less favorable .
the left atrium can receive blood from the right heart and bronchial circulation . in the case of severe lv dysfunction
, the lv can not eject the received blood to overcome the increased afterload due to the retrograde p - ecls flow .
the consequences of lv distension include pulmonary edema , pulmonary hemorrhage , right ventricular distension , and increased intraventricular pressure , which can lead to myocardial hypoperfusion and ischemia .
the effect of p - ecls on lv distension was investigated previously by some authors . in an animal model of acute heart failure ,
kawashima et al .   reported that the resolution of ventricular fibrillation was related to lv unloading and reduction in myocardial oxygen consumption .
myocardial perfusion is proportional to the decrease in the lv wall tension and the compression of intra - myocardial coronary vessels .
therefore , lv decompression favorably affects ventricular recovery and increases the possibility of weaning from p - ecls . for this reason , a careful evaluation of the status of the lv and prompt drainage in the case of a pressure increase
there are several techniques to decompress the lv , including a percutaneous trans - septal left atrial approach , lv venting through the right upper pulmonary vein , and direct lv apex cannulation . although percutaneous lv venting does not require a surgical incision , the effectiveness of lv decompression can be limited according to the degree of mitral regurgitation . thus , surgical venting is a more favorable option than percutaneous septostomy .
reported minimally invasive lv drainage in which an apical cannula is inserted into the lv apex transcutaneously .
although direct drainage of the lv through a trans - sternal approach is technically more complex , it has the advantage of high efficacy with respect to the intraventricular dynamics .
further , our group was more familiar with the trans - sternal approach at that time .
management after an lv venting procedure is still controversial , particularly since there is uncertainty in terms of patient stability after weaning from p - ecls .
there are three ways of weaning from venoarterial ecls , namely the one - stage removal of all ecls cannulae , vent catheter removal and subsequent venoarterial ecls weaning , and venous cannula removal and subsequent paracorporeal lvad weaning . in this case
, we decided to shift to paracorporeal lvad from p - ecls by progressively clamping the venous line and lowering the flow to the oxygenator until complete exclusion from the circuit .
this allows for a heparin- and oxygenator - free trial of extracorporeal circulation , which reduces the chances of bleeding or thromboembolism .
the low risk of bleeding and thromboembolism allows longer - term support for heart transplant than venoarterial ecls
. the other advantages of our strategy include prevention of recurrent lv distension and pulmonary edema . in summary ,
p - ecls offers excellent circulatory support in emergency settings and assures rapid and systemic perfusion .
however , p - ecls can negatively affect lv physiology and can potentially jeopardize myocardial recovery .
thus , a careful evaluation of the lv status and prompt drainage in the case of pressure increases should be considered .
our strategy assures complete lv venting and allows for a simple conversion of p - ecls to paracorporeal lvad .
 percutaneous extracorporeal life support ( p - ecls ) is a useful modality for the management of refractory cardiac or pulmonary failure . 
 however , venoarterial p - ecls may result in a complication of left ventricular distension . in this case report 
 , we discuss a patient with drug - induced dilated cardiomyopathy managed with venoarterial p - ecls and a left atrial vent catheter . 
 the venoarterial p - ecls was modified to a paracorporeal left ventricular assist device ( lvad ) by removing the femoral venous cannula . 
 after 28 days of hospitalization , the patient was successfully weaned from the paracorporeal lvad and discharged home from the hospital . 