Left atrial appendage cannulation for left ventricular unloading in a patient with ventricular thrombus on extracorporeal life support

Left atrial appendage cannulation for left ventricular unloading in a patient with ventricular thrombus on extracorporeal life support | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Left atrial appendage cannulation for left ventricular unloading in a patient with ventricular thrombus on extracorporeal life support Anne-Kristin Schaefer, Dominik Wiedemann, Gottfried Heinz, Julia Riebandt, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5210610/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 10 Jan, 2025 Read the published version in Journal of Cardiothoracic Surgery → Version 1 posted 18 You are reading this latest preprint version Abstract Background Left ventricular unloading is needed in patients on extracorporeal life support (ECLS) with severely reduced left ventricular contractility to avoid stasis and pulmonary congestion, and to promote LV recovery. The presence of thrombi in the LV precludes the use of conventional active unloading methods such as transaortic microaxial pumps or apical LV vents. We describe placement of a vent cannula via the left atrial appendage (LAA) as a useful bailout option. Case Presentation: A 61-year-old patient presenting with normotensive cardiogenic shock (SCAI C) after subacute anterior wall myocardial infarction deteriorated with pulmonary edema and ventricular fibrilation, requiring veno-arterial extracorporeal life support under ongoing CPR (SCAI E). An Impella CP was placed for LV unloading, but was unable to generate flow and removed. A large left ventricular thrombus was detected as the cause for insufficient Impella flow. For urgent LV unloading, we placed a vent cannula via the LAA through a thoracotomy to bridge our patient to total artificial heart implantation. However, intraoperative TEE showed resolution of the LV thrombus, enabling to change the strategy to left ventricular assist device implantation. Our patient made a full recovery and is now doing well in regular outpatient follow ups. Conclusions ECLS provides excellent circulatory support at the price of a high complication burden and considerable LV afterload increase. ECLS complications often require individualized solutions not represented in current HF guidelines. This patient has developed a dreaded and nearly always fatal ECLS complication, which was successfully managed with vent placement via the LAA. Temporary mechanical circulatory support extracorporeal life support extracorporeal membrane oxygenation LV unloading case report Figures Figure 1 Figure 2 Figure 3 Figure 4 Background While extracorporeal life support (ECLS) provides excellent circulatory support and reversal of hypoperfusion syndrome, it considerably increases LV afterload, filling pressures and wall stress. ( 1 ) Particularly in patients with severely reduced LV function and limited contractile reserve, this often leads to a critical drop in stroke volume and catastrophic complications such as pulmonary edema, stasis and thrombus formation, and compromised myocardial recovery. ( 1 ) The presence of thrombi in the LV precludes use of microaxial flow pumps or apical vents for unloading, thus alternative techniques are needed. Case Presentation A 61-year-old male patient was transferred to our center with subacute anterior wall myocardial infarction one day after admission in a primary care center. Past medical history was significant for insulin-dependent diabetes mellitus II(HbA1c 104mmol/mol), a one-week history of shortness of breath, and reduced exercise tolerance for the past two months. Upon arrival, the patient was awake and normotensive without catecholamine support. He showed clinical and laboratory signs of hypoperfusion syndrome with skin mottling, mental confusion and oliguria, lactate 5.7 mmol/l, creatinine 1,57 mg/dl, ASAT 132U/L, ALAT 64U/L, Troponin-T 855ng/L, CK 709U/L, CK-MB 79.8U/L(11.3%), pro-BNP 6347pg/mL. Transthoracic echocardiography showed severe left ventricular dysfunction with LVEF of approximately 15% and akinesia of the posterior wall, the apex, and the mid-ventricular anterior wall, and no significant valvular lesions. ECG showed a left posterior hemiblock (LPH), absence of R-wave progression in leads V1 to V3, and Q waves and ST-segment elevations in leads II, III, and aVF. Diagnostic coronary angiography revealed complex triple vessel disease. Specifically, significant distal left main stenosis presenting as a bifurcation lesion at the origin of the proximal circumflex artery. There was also significant stenosis in the ostial to mid-segments, as well as the distal segment of the LAD, and in the first diagonal branch. Angiography also showed a non-significant stenosis in the proximal segment of the circumflex artery. and a chronic total occlusion of the mid-circumflex artery at the origin of the second marginal branch, presenting another bifurcation lesion. Figure 1 a + b Furthermore, a chronic total occlusion was noted in the proximal right coronary artery, with collateral circulation from the left coronary system. Figure 1 c Given the subacute presentation, a conservative management was initially opted for. The goal was to optimize hemodynamic status and organ function. Following comprehensive myocardial viability assessment, the heart team would consider advanced revascularization options. Potential interventions included an Impella-assisted PCI or CABG, contingent upon viability and overall clinical assessment. However, shortly after angiography, the patient developed pulmonary edema and ventricular fibrillation, and ECLS was implanted after 31 minutes of CPR in the setting of refractory VF and multiple unsuccessful defibrillation attempts. VF persisted on ECLS and the decision for PCI was made. The procedure started with intubation using a 3.5 Fr.7 Launcher guiding catheter and an ASAHI SION blue 190cm guidewire to navigate lesions in the mid-LAD and the first diagonal branch, with a BMW guidewire for the mid-circumflex artery lesion. The first diagonal branch was dilated using a PIPIT 2x15mm balloon. The mid to proximal LAD underwent dilation with Ikazuchi Zero and SLR balloons, and two DES were placed in the mid to ostial LAD. The left main stem and proximal circumflex artery were dilated with Accuforce balloons. A DES was placed in the circumflex artery, followed by a crush technique and kissing balloon dilatation in the main stem using NC balloons and a Megatron DES. The procedure concluded with post-dilatation optimization and further kissing balloon dilatation, achieving satisfactory results. Despite regaining sinus rhythm, absence of aortic valve opening persisted, and TEE showed beginning thrombus formation/smoke-like effect in the left ventricle. An Impella CP was implanted to allow for LV unloading. However, the Impella was not able to generate sufficient flow, and TEE revealed a large thrombus had formed in the left ventricle, Fig. 2 and the dysfunctional Impella was removed. CCT revealed a minor cardioembolic stroke, however, he was clinically responsive after CPR. Since the left atrium and LAA were free from thrombus formation, after interdisciplinary discussion, we opted for surgical placement of a vent cannula via the LAA as bailout option to bridge our patient to possible durable MCS. A left lateral thoracotomy in the third intercostal space was performed followed by dorsal retraction of the left lung to expose the pericardium, which was opened 2 cm anterior to the phrenic nerve to vizualize the LAA. Figure 4 a Two pledgeted pursestring sutures were placed, and a 20Fr straight single-stage wire reinforced venous cannula (Medtronic DLP) was tunneled through the thoracic wall below the incision. The LAA was incised and the cannula advanced into the left atrium under TEE guidance. Figure 4 b The LAA cannula was then connected to the venous line of the ECLS circuit. Figure 4 c Our patient stabilized, and a repeat CCT showed neither progression of ischemic areas nor hemorrhage, thus he was now eligible for durable MCS. Because of the large LV thrombus precluding conventional LVAD implantation, he was scheduled to receive a total artificial heart(HM6). ( 2 ) However, at the time of surgery five days after LAA vent implantation, intraoperative TEE unexpectedly revealed resolution of the LV thrombus, Fig. 3 and thus the strategy was changed to LVAD with temporary RVAD implantation, which was carried out uneventfully via a median sternotomy on cardiopulmonary bypass. ECLS was explanted. On POD 1, our patient developed left leg ischemia and CTA revealed left common femoral artery dissection, possibly originating from PCI access. He underwent successful iliaco-femoral bypass surgery. The postoperative course was furthermore complicated by duodenal hemorrhage requiring endoscopic clipping. The tRVAD was weaned and explanted on POD 9. Tracheostomy was performed, and he was decannulated on POD 39, transferred to a ward on POD 42 and discharged to the rehabilitation center on POD 87. Our patient is currently on LVAD support for 342 days without readmissions and is doing well in regular outpatient follow ups. While being eligible for HTX, he has not yet decided whether he wants to undergo listing. Discussion and Conclusions The Society for Cardiovascular Angiography and Intervention(SCAI) proposes the use of tMCS in the presence of hypoperfusion syndrome(SCAI C-E), as bridge to recovery or durable MCS/HTX, ( 3 ) in consensus with current ESC-HF guidelines(Iia/C). ( 4 ) Close observation is essential in conservatively managed CS patients because of frequent progression to SCAI D + E. A proactive tMCS use could have prevented deterioration in our patient, however, ECLS carries a high complication burden, thus selective use and timing are essentially important. ( 5 , 6 ) While ECLS is often required in patients presenting with shock stages D + E, microaxial pumps may be favorable in SCAI-C CS with predominant LV failure. ( 7 ) While various hemodynamic and echocardiographic criteria have been suggested to compile recommendations on indications and timing for active LV unloading during ECLS, criteria remain to be supported by ongoing trials. ( 8 ) There is, however, widespread consensus on the benefit of unloading in patients who receive ECLS for CS originating from LV failure, even more so in presence of concomitant leftsided valve regurgitation. ( 1 , 9 , 10 ) An RCT evaluating ECLS in infarct-related CS showed no benefit of ECLS with underutilization of unloading. ( 11 ) Unloading should be established at the same time, or immediately after ECLS initiation, ( 12 ) followed by stepwise de-escalation of tMCS. Use of Impella 5.5 for ECMELLA facilitates de-escalation since full and prolonged LV support can be provided, yielding time for decision-making on potential recovery or bridging options, as well as discussing those with the patient. ( 13 ) In the presented case, Impella was contraindicated in the presence of a large LV thrombus. Placement of an LAA vent cannula is technically simple and seems to have effectively addressed stasis in the LV. A percutaneous alternative to LA venting via thoracotomy is left-atrial-veno-arterial (LA-VA)-ECMO with transseptal placement of the venous drainage cannula tip in the left atrium. ( 14 , 15 ) In summary, patient selection, timing and ICU management including escalation and de-escalation strategies are foundations for successful tMCS treatment. ECLS-related complications frequently require solutions not represented by current guidelines. List of Abbreviations CCT cerebral computed tomography CS cardiogenic shock ECLS extracorporeal life support LV left ventricle LVAD left ventricular assist device RCT randomized controlled trial SCAI Society for Cardiovascular Angiography and Intervention tMCS temporary mechanical circulatory support Declarations Ethics approval and consent to participate Ethics approval was waived due to the retrospective character of the study. The patient whose case is reported consented to reporting and publication of the case. Consent for publication The patient whose case is reported gave written consent to publication of the case. Availability of data and materials Not applicable. Competing interests None Funding None Authors' contributions A.S. and R.Z.: conceptualization, review of the patient’s clinical course and imaging, writing of manuscript draft; D.W., G.H. and J.R.: supervision, review and editing of the manuscript draft, case discussion in context of existing literature Acknowledgements None References Ezad SM, Ryan M, Donker DW, Pappalardo F, Barrett N, Camporota L, et al. Unloading the Left Ventricle in Venoarterial ECMO: In Whom, When, and How? Circulation. 2023;147(16):1237–50. Urganci E, Wiedemann D, Riebandt J, Schaefer AK, Hornykewycz S, Laufer G et al. Implanting the HeartMate 6 (total artificial heart). Multimed Man Cardiothorac Surg. 2021;2021. Møller JE, Sionis A, Aissaoui N, Ariza A, Bělohlávek J, De Backer D, et al. Step by step daily management of short-term mechanical circulatory support for cardiogenic shock in adults in the intensive cardiac care unit: a clinical consensus statement of the Association for Acute CardioVascular Care of the European Society of Cardiology SC, the European Society of Intensive Care Medicine, the European branch of the Extracorporeal Life Support Organization, and the European Association for Cardio-Thoracic Surgery. Eur Heart J Acute Cardiovasc Care. 2023;12(7):475–85. McDonagh TA, Metra M, Adamo M, Gardner RS, Baumbach A, Böhm M, et al. 2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure. Eur Heart J. 2021;42(36):3599–726. Cheng R, Hachamovitch R, Kittleson M, Patel J, Arabia F, Moriguchi J, et al. Complications of extracorporeal membrane oxygenation for treatment of cardiogenic shock and cardiac arrest: a meta-analysis of 1,866 adult patients. Ann Thorac Surg. 2014;97(2):610–6. Distelmaier K, Wiedemann D, Binder C, Haberl T, Zimpfer D, Heinz G, et al. Duration of extracorporeal membrane oxygenation support and survival in cardiovascular surgery patients. J Thorac Cardiovasc Surg. 2018;155(6):2471–6. Møller JE, Engstrøm T, Jensen LO, Eiskjær H, Mangner N, Polzin A, et al. Microaxial Flow Pump or Standard Care in Infarct-Related Cardiogenic Shock. N Engl J Med. 2024;390(15):1382–93. Schrage B. UNLOAD-ECMO Randomised Controlled Trial for Left Ventricular Unloading with Veno-arterial Extracorporeal Membrane Oxygenation in Severe Cardiogenic Shock. Interventional Cardiology. 2024;19(Suppl 1):17–8. 2024. Lorusso R, Whitman G, Milojevic M, Raffa G, McMullan DM, Boeken U, et al. 2020 EACTS/ELSO/STS/AATS expert consensus on post-cardiotomy extracorporeal life support in adult patients. J Thorac Cardiovasc Surg. 2021;161(4):1287–331. Lorusso R, Meani P, Raffa GM, Kowalewski M. Extracorporeal membrane oxygenation and left ventricular unloading: What is the evidence? JTCVS Tech. 2022;13:101–14. Thiele H, Zeymer U, Akin I, Behnes M, Rassaf T, Mahabadi AA, et al. Extracorporeal Life Support in Infarct-Related Cardiogenic Shock. N Engl J Med. 2023;389(14):1286–97. Schrage B, Sundermeyer J, Blankenberg S, Colson P, Eckner D, Eden M, et al. Timing of Active Left Ventricular Unloading in Patients on Venoarterial Extracorporeal Membrane Oxygenation Therapy. JACC Heart Fail. 2023;11(3):321–30. Schrage B, Bernhardt A, Potapov E, Bertoldi LF, Mangner N. From escalation to weaning strategies: how to integrate the ECMELLA concept. Eur Heart J Suppl. 2023;25(Suppl I):I39–43. Lemor A, Basir MB, O'Neill BP, Cowger J, Frisoli T, Lee JC, et al. Left Atrial-Veno-Arterial Extracorporeal Membrane Oxygenation: Step-By-Step Procedure and Case Example. Struct Heart. 2022;6(6):100117. Jong HC, Ngoh K, Lu TY, Wang TJ. Left Atrial Decompression during Veno-Arterial Extracorporeal Membrane Oxygenation Support by Advancing Venous Cannula to Left Atrium after Balloon Atrial Septectomy. Acta Cardiol Sin. 2023;39(1):194–7. Additional Declarations No competing interests reported. Supplementary Files SummaryFigure.docx Cite Share Download PDF Status: Published Journal Publication published 10 Jan, 2025 Read the published version in Journal of Cardiothoracic Surgery → Version 1 posted Editorial decision: Revision requested 02 Nov, 2024 Reviews received at journal 30 Oct, 2024 Reviews received at journal 26 Oct, 2024 Reviewers agreed at journal 26 Oct, 2024 Reviews received at journal 25 Oct, 2024 Reviews received at journal 25 Oct, 2024 Reviews received at journal 21 Oct, 2024 Reviewers agreed at journal 19 Oct, 2024 Reviewers agreed at journal 18 Oct, 2024 Reviewers agreed at journal 17 Oct, 2024 Reviewers agreed at journal 17 Oct, 2024 Reviewers agreed at journal 17 Oct, 2024 Reviewers agreed at journal 16 Oct, 2024 Reviewers agreed at journal 16 Oct, 2024 Reviewers invited by journal 16 Oct, 2024 Editor assigned by journal 06 Oct, 2024 Submission checks completed at journal 06 Oct, 2024 First submitted to journal 05 Oct, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5210610","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":373220577,"identity":"ab6ca299-ac95-447e-8819-344d40502002","order_by":0,"name":"Anne-Kristin Schaefer","email":"data:image/png;base64,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","orcid":"","institution":"Medical University of Vienna","correspondingAuthor":true,"prefix":"","firstName":"Anne-Kristin","middleName":"","lastName":"Schaefer","suffix":""},{"id":373220578,"identity":"bf83e234-84d0-4d80-89de-977f324c253a","order_by":1,"name":"Dominik Wiedemann","email":"","orcid":"","institution":"Karl Landsteiner University, University Clinic St. Pölten","correspondingAuthor":false,"prefix":"","firstName":"Dominik","middleName":"","lastName":"Wiedemann","suffix":""},{"id":373220579,"identity":"dcbc2e14-40a6-4d1f-b405-63f81a88f88a","order_by":2,"name":"Gottfried Heinz","email":"","orcid":"","institution":"Medical University of Vienna","correspondingAuthor":false,"prefix":"","firstName":"Gottfried","middleName":"","lastName":"Heinz","suffix":""},{"id":373220580,"identity":"609cea71-b2d9-4bae-8771-4e21a8720082","order_by":3,"name":"Julia Riebandt","email":"","orcid":"","institution":"Medical University of Vienna","correspondingAuthor":false,"prefix":"","firstName":"Julia","middleName":"","lastName":"Riebandt","suffix":""},{"id":373220581,"identity":"1640b68b-ea15-4944-aa98-d00a666f5135","order_by":4,"name":"Robert Zilberszac","email":"","orcid":"","institution":"Medical University of Vienna","correspondingAuthor":false,"prefix":"","firstName":"Robert","middleName":"","lastName":"Zilberszac","suffix":""}],"badges":[],"createdAt":"2024-10-05 22:53:06","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5210610/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5210610/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s13019-024-03288-4","type":"published","date":"2025-01-10T15:57:05+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":70287809,"identity":"7a7bfc23-c70d-4d98-8e5f-8fca44ef12ad","added_by":"auto","created_at":"2024-12-01 16:57:51","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":1675060,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003ea\u003c/strong\u003e - RAO caudal view showing significant stenosis in the distal left main coronary artery at the bifurcation of the proximal circumflex artery. The LAD has significant stenosis in its ostial to mid and distal segments, including the first diagonal branch. Non-significant stenosis is seen in the proximal circumflex artery, with chronic total occlusion in the mid-circumflex artery at the origin of the second marginal branch\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFigure 1b \u003c/strong\u003e- LAO caudal view displaying a distal left main bifurcation lesion and diffusely diseased LAD and diagonal branch.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFigure 1c \u003c/strong\u003e- LAO cranial view showing chronic total occlusion of the RCA\u003c/p\u003e","description":"","filename":"FIGURE1.png","url":"https://assets-eu.researchsquare.com/files/rs-5210610/v1/23d13d5c2222ef2ed69dc2a5.png"},{"id":70287092,"identity":"26720c99-8ad5-4398-b276-5c100ec912c8","added_by":"auto","created_at":"2024-12-01 16:49:51","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":291415,"visible":true,"origin":"","legend":"\u003cp\u003eTransesophageal echocardiogram illustrating significant intracavitary thrombus formation within the left ventricle\u003c/p\u003e","description":"","filename":"FIGURE2.png","url":"https://assets-eu.researchsquare.com/files/rs-5210610/v1/59222bd6cc60bfb3bc7361a3.png"},{"id":70287091,"identity":"31dad44c-201a-49df-8a9f-15841fd76a67","added_by":"auto","created_at":"2024-12-01 16:49:51","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":330606,"visible":true,"origin":"","legend":"\u003cp\u003eIntraoperative transesophageal echocardiogram: The intracavitary thrombus had completely resolved by the time of LVAD implantation. The inflow cannula of the LVAD is visible in the left ventricular apex.\u003c/p\u003e","description":"","filename":"FIGURE3.png","url":"https://assets-eu.researchsquare.com/files/rs-5210610/v1/8f8887df5d18c725a2448be9.png"},{"id":70287089,"identity":"0f1f56a0-7d72-460c-b967-ba0f11a9c70d","added_by":"auto","created_at":"2024-12-01 16:49:51","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":1823253,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eECLS setup. A) \u003c/strong\u003eA thoracoctomy in the 3rd intercostal space is performed and the pericardium opened anterior to the phrenic nerve to expose the LAA. \u003cstrong\u003eB)\u003c/strong\u003e A 20F straight tip wire-reinforced venous cannula is tunneled through the thoracic wall and inserted into the LA through a purse-string suture under TEE guidance. \u003cstrong\u003eC) \u003c/strong\u003eThe LAA vent line is connected to the venous line of the ECLS circuit.\u003c/p\u003e","description":"","filename":"FIGURE4.png","url":"https://assets-eu.researchsquare.com/files/rs-5210610/v1/0b0edfdab09bce0a900aa74d.png"},{"id":73693846,"identity":"531f2751-c615-4521-a6a6-a0435701c847","added_by":"auto","created_at":"2025-01-13 16:08:26","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":4999521,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5210610/v1/ec877830-8a4d-4d6f-a5f2-1a0e2f45a0e3.pdf"},{"id":70287088,"identity":"59aa4ac4-558a-41cf-8a7c-65c2570a6a10","added_by":"auto","created_at":"2024-12-01 16:49:51","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":32333,"visible":true,"origin":"","legend":"","description":"","filename":"SummaryFigure.docx","url":"https://assets-eu.researchsquare.com/files/rs-5210610/v1/6e35c0ff005cda3048c3fc04.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Left atrial appendage cannulation for left ventricular unloading in a patient with ventricular thrombus on extracorporeal life support","fulltext":[{"header":"Background","content":"\u003cp\u003eWhile extracorporeal life support (ECLS) provides excellent circulatory support and reversal of hypoperfusion syndrome, it considerably increases LV afterload, filling pressures and wall stress. (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) Particularly in patients with severely reduced LV function and limited contractile reserve, this often leads to a critical drop in stroke volume and catastrophic complications such as pulmonary edema, stasis and thrombus formation, and compromised myocardial recovery. (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eThe presence of thrombi in the LV precludes use of microaxial flow pumps or apical vents for unloading, thus alternative techniques are needed.\u003c/p\u003e"},{"header":"Case Presentation","content":"\u003cp\u003eA 61-year-old male patient was transferred to our center with subacute anterior wall myocardial infarction one day after admission in a primary care center. Past medical history was significant for insulin-dependent diabetes mellitus II(HbA1c 104mmol/mol), a one-week history of shortness of breath, and reduced exercise tolerance for the past two months.\u003c/p\u003e \u003cp\u003eUpon arrival, the patient was awake and normotensive without catecholamine support. He showed clinical and laboratory signs of hypoperfusion syndrome with skin mottling, mental confusion and oliguria, lactate 5.7 mmol/l, creatinine 1,57 mg/dl, ASAT 132U/L, ALAT 64U/L, Troponin-T 855ng/L, CK 709U/L, CK-MB 79.8U/L(11.3%), pro-BNP 6347pg/mL.\u003c/p\u003e \u003cp\u003eTransthoracic echocardiography showed severe left ventricular dysfunction with LVEF of approximately 15% and akinesia of the posterior wall, the apex, and the mid-ventricular anterior wall, and no significant valvular lesions.\u003c/p\u003e \u003cp\u003eECG showed a left posterior hemiblock (LPH), absence of R-wave progression in leads V1 to V3, and Q waves and ST-segment elevations in leads II, III, and aVF.\u003c/p\u003e \u003cp\u003eDiagnostic coronary angiography revealed complex triple vessel disease. Specifically, significant distal left main stenosis presenting as a bifurcation lesion at the origin of the proximal circumflex artery. There was also significant stenosis in the ostial to mid-segments, as well as the distal segment of the LAD, and in the first diagonal branch. Angiography also showed a non-significant stenosis in the proximal segment of the circumflex artery. and a chronic total occlusion of the mid-circumflex artery at the origin of the second marginal branch, presenting another bifurcation lesion. Figure\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e1\u003c/span\u003ea \u003cb\u003e+ b\u003c/b\u003e Furthermore, a chronic total occlusion was noted in the proximal right coronary artery, with collateral circulation from the left coronary system. Figure\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e1\u003c/span\u003ec\u003c/p\u003e \u003cp\u003eGiven the subacute presentation, a conservative management was initially opted for. The goal was to optimize hemodynamic status and organ function. Following comprehensive myocardial viability assessment, the heart team would consider advanced revascularization options. Potential interventions included an Impella-assisted PCI or CABG, contingent upon viability and overall clinical assessment.\u003c/p\u003e \u003cp\u003eHowever, shortly after angiography, the patient developed pulmonary edema and ventricular fibrillation, and ECLS was implanted after 31 minutes of CPR in the setting of refractory VF and multiple unsuccessful defibrillation attempts. VF persisted on ECLS and the decision for PCI was made. The procedure started with intubation using a 3.5 Fr.7 Launcher guiding catheter and an ASAHI SION blue 190cm guidewire to navigate lesions in the mid-LAD and the first diagonal branch, with a BMW guidewire for the mid-circumflex artery lesion. The first diagonal branch was dilated using a PIPIT 2x15mm balloon. The mid to proximal LAD underwent dilation with Ikazuchi Zero and SLR balloons, and two DES were placed in the mid to ostial LAD. The left main stem and proximal circumflex artery were dilated with Accuforce balloons. A DES was placed in the circumflex artery, followed by a crush technique and kissing balloon dilatation in the main stem using NC balloons and a Megatron DES. The procedure concluded with post-dilatation optimization and further kissing balloon dilatation, achieving satisfactory results. Despite regaining sinus rhythm, absence of aortic valve opening persisted, and TEE showed beginning thrombus formation/smoke-like effect in the left ventricle. An Impella CP was implanted to allow for LV unloading. However, the Impella was not able to generate sufficient flow, and TEE revealed a large thrombus had formed in the left ventricle, Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e2\u003c/span\u003e and the dysfunctional Impella was removed.\u003c/p\u003e \u003cp\u003eCCT revealed a minor cardioembolic stroke, however, he was clinically responsive after CPR.\u003c/p\u003e \u003cp\u003eSince the left atrium and LAA were free from thrombus formation, after interdisciplinary discussion, we opted for surgical placement of a vent cannula via the LAA as bailout option to bridge our patient to possible durable MCS.\u003c/p\u003e \u003cp\u003eA left lateral thoracotomy in the third intercostal space was performed followed by dorsal retraction of the left lung to expose the pericardium, which was opened 2 cm anterior to the phrenic nerve to vizualize the LAA. Figure\u0026nbsp;\u003cspan refid=\"Fig6\" class=\"InternalRef\"\u003e4\u003c/span\u003ea Two pledgeted pursestring sutures were placed, and a 20Fr straight single-stage wire reinforced venous cannula (Medtronic DLP) was tunneled through the thoracic wall below the incision. The LAA was incised and the cannula advanced into the left atrium under TEE guidance. Figure\u0026nbsp;\u003cspan refid=\"Fig6\" class=\"InternalRef\"\u003e4\u003c/span\u003eb The LAA cannula was then connected to the venous line of the ECLS circuit. Figure\u0026nbsp;\u003cspan refid=\"Fig6\" class=\"InternalRef\"\u003e4\u003c/span\u003ec\u003c/p\u003e \u003cp\u003eOur patient stabilized, and a repeat CCT showed neither progression of ischemic areas nor hemorrhage, thus he was now eligible for durable MCS. Because of the large LV thrombus precluding conventional LVAD implantation, he was scheduled to receive a total artificial heart(HM6). (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) However, at the time of surgery five days after LAA vent implantation, intraoperative TEE unexpectedly revealed resolution of the LV thrombus, Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e3\u003c/span\u003e and thus the strategy was changed to LVAD with temporary RVAD implantation, which was carried out uneventfully via a median sternotomy on cardiopulmonary bypass. ECLS was explanted.\u003c/p\u003e \u003cp\u003eOn POD 1, our patient developed left leg ischemia and CTA revealed left common femoral artery dissection, possibly originating from PCI access. He underwent successful iliaco-femoral bypass surgery. The postoperative course was furthermore complicated by duodenal hemorrhage requiring endoscopic clipping. The tRVAD was weaned and explanted on POD 9. Tracheostomy was performed, and he was decannulated on POD 39, transferred to a ward on POD 42 and discharged to the rehabilitation center on POD 87.\u003c/p\u003e \u003cp\u003eOur patient is currently on LVAD support for 342 days without readmissions and is doing well in regular outpatient follow ups. While being eligible for HTX, he has not yet decided whether he wants to undergo listing.\u003c/p\u003e "},{"header":"Discussion and Conclusions","content":"\u003cp\u003eThe Society for Cardiovascular Angiography and Intervention(SCAI) proposes the use of tMCS in the presence of hypoperfusion syndrome(SCAI C-E), as bridge to recovery or durable MCS/HTX, (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e) in consensus with current ESC-HF guidelines(Iia/C). (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e) Close observation is essential in conservatively managed CS patients because of frequent progression to SCAI D + E. A proactive tMCS use could have prevented deterioration in our patient, however, ECLS carries a high complication burden, thus selective use and timing are essentially important. (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e) While ECLS is often required in patients presenting with shock stages D + E, microaxial pumps may be favorable in SCAI-C CS with predominant LV failure. (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e)\u003c/p\u003e\u003cp\u003eWhile various hemodynamic and echocardiographic criteria have been suggested to compile recommendations on indications and timing for active LV unloading during ECLS, criteria remain to be supported by ongoing trials. (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e) There is, however, widespread consensus on the benefit of unloading in patients who receive ECLS for CS originating from LV failure, even more so in presence of concomitant leftsided valve regurgitation. (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e) An RCT evaluating ECLS in infarct-related CS showed no benefit of ECLS with underutilization of unloading. (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e)\u003c/p\u003e\u003cp\u003eUnloading should be established at the same time, or immediately after ECLS initiation, (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e) followed by stepwise de-escalation of tMCS. Use of Impella 5.5 for ECMELLA facilitates de-escalation since full and prolonged LV support can be provided, yielding time for decision-making on potential recovery or bridging options, as well as discussing those with the patient. (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e)\u003c/p\u003e\u003cp\u003eIn the presented case, Impella was contraindicated in the presence of a large LV thrombus. Placement of an LAA vent cannula is technically simple and seems to have effectively addressed stasis in the LV.\u003c/p\u003e\u003cp\u003eA percutaneous alternative to LA venting via thoracotomy is left-atrial-veno-arterial (LA-VA)-ECMO with transseptal placement of the venous drainage cannula tip in the left atrium. (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e)\u003c/p\u003e\u003cp\u003eIn summary, patient selection, timing and ICU management including escalation and de-escalation strategies are foundations for successful tMCS treatment. ECLS-related complications frequently require solutions not represented by current guidelines.\u003c/p\u003e"},{"header":"List of Abbreviations","content":"\u003cp\u003e\u003cstrong\u003eCCT\u0026nbsp;\u003c/strong\u003ecerebral computed tomography\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCS\u0026nbsp;\u003c/strong\u003ecardiogenic shock\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eECLS\u0026nbsp;\u003c/strong\u003eextracorporeal life support\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLV\u0026nbsp;\u003c/strong\u003eleft ventricle\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLVAD\u003c/strong\u003e left ventricular assist device\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eRCT\u0026nbsp;\u003c/strong\u003erandomized controlled trial\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSCAI\u0026nbsp;\u003c/strong\u003eSociety for Cardiovascular Angiography and Intervention\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003etMCS\u0026nbsp;\u003c/strong\u003etemporary mechanical circulatory support\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthics approval was waived due to the retrospective character of the study. The patient whose case is reported consented to reporting and publication of the case.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe patient whose case is reported gave written consent to publication of the case.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNone\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNone\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA.S. and R.Z.: conceptualization, review of the patient\u0026rsquo;s clinical course and imaging, writing of manuscript draft; D.W., G.H. and J.R.: supervision, review and editing of the manuscript draft, case discussion in context of existing literature\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNone\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eEzad SM, Ryan M, Donker DW, Pappalardo F, Barrett N, Camporota L, et al. Unloading the Left Ventricle in Venoarterial ECMO: In Whom, When, and How? Circulation. 2023;147(16):1237\u0026ndash;50.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eUrganci E, Wiedemann D, Riebandt J, Schaefer AK, Hornykewycz S, Laufer G et al. Implanting the HeartMate 6 (total artificial heart). Multimed Man Cardiothorac Surg. 2021;2021.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eM\u0026oslash;ller JE, Sionis A, Aissaoui N, Ariza A, Bělohl\u0026aacute;vek J, De Backer D, et al. Step by step daily management of short-term mechanical circulatory support for cardiogenic shock in adults in the intensive cardiac care unit: a clinical consensus statement of the Association for Acute CardioVascular Care of the European Society of Cardiology SC, the European Society of Intensive Care Medicine, the European branch of the Extracorporeal Life Support Organization, and the European Association for Cardio-Thoracic Surgery. Eur Heart J Acute Cardiovasc Care. 2023;12(7):475\u0026ndash;85.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMcDonagh TA, Metra M, Adamo M, Gardner RS, Baumbach A, B\u0026ouml;hm M, et al. 2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure. Eur Heart J. 2021;42(36):3599\u0026ndash;726.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCheng R, Hachamovitch R, Kittleson M, Patel J, Arabia F, Moriguchi J, et al. Complications of extracorporeal membrane oxygenation for treatment of cardiogenic shock and cardiac arrest: a meta-analysis of 1,866 adult patients. Ann Thorac Surg. 2014;97(2):610\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDistelmaier K, Wiedemann D, Binder C, Haberl T, Zimpfer D, Heinz G, et al. Duration of extracorporeal membrane oxygenation support and survival in cardiovascular surgery patients. J Thorac Cardiovasc Surg. 2018;155(6):2471\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eM\u0026oslash;ller JE, Engstr\u0026oslash;m T, Jensen LO, Eiskj\u0026aelig;r H, Mangner N, Polzin A, et al. Microaxial Flow Pump or Standard Care in Infarct-Related Cardiogenic Shock. N Engl J Med. 2024;390(15):1382\u0026ndash;93.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSchrage B. UNLOAD-ECMO Randomised Controlled Trial for Left Ventricular Unloading with Veno-arterial Extracorporeal Membrane Oxygenation in Severe Cardiogenic Shock. Interventional Cardiology. 2024;19(Suppl 1):17\u0026ndash;8. 2024.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLorusso R, Whitman G, Milojevic M, Raffa G, McMullan DM, Boeken U, et al. 2020 EACTS/ELSO/STS/AATS expert consensus on post-cardiotomy extracorporeal life support in adult patients. J Thorac Cardiovasc Surg. 2021;161(4):1287\u0026ndash;331.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLorusso R, Meani P, Raffa GM, Kowalewski M. Extracorporeal membrane oxygenation and left ventricular unloading: What is the evidence? JTCVS Tech. 2022;13:101\u0026ndash;14.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eThiele H, Zeymer U, Akin I, Behnes M, Rassaf T, Mahabadi AA, et al. Extracorporeal Life Support in Infarct-Related Cardiogenic Shock. N Engl J Med. 2023;389(14):1286\u0026ndash;97.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSchrage B, Sundermeyer J, Blankenberg S, Colson P, Eckner D, Eden M, et al. Timing of Active Left Ventricular Unloading in Patients on Venoarterial Extracorporeal Membrane Oxygenation Therapy. JACC Heart Fail. 2023;11(3):321\u0026ndash;30.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSchrage B, Bernhardt A, Potapov E, Bertoldi LF, Mangner N. From escalation to weaning strategies: how to integrate the ECMELLA concept. Eur Heart J Suppl. 2023;25(Suppl I):I39\u0026ndash;43.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLemor A, Basir MB, O'Neill BP, Cowger J, Frisoli T, Lee JC, et al. Left Atrial-Veno-Arterial Extracorporeal Membrane Oxygenation: Step-By-Step Procedure and Case Example. Struct Heart. 2022;6(6):100117.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJong HC, Ngoh K, Lu TY, Wang TJ. Left Atrial Decompression during Veno-Arterial Extracorporeal Membrane Oxygenation Support by Advancing Venous Cannula to Left Atrium after Balloon Atrial Septectomy. Acta Cardiol Sin. 2023;39(1):194\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"journal-of-cardiothoracic-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jcts","sideBox":"Learn more about [Journal of Cardiothoracic Surgery](http://cardiothoracicsurgery.biomedcentral.com)","snPcode":"13019","submissionUrl":"https://submission.nature.com/new-submission/13019/3","title":"Journal of Cardiothoracic Surgery","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Temporary mechanical circulatory support, extracorporeal life support, extracorporeal membrane oxygenation, LV unloading, case report","lastPublishedDoi":"10.21203/rs.3.rs-5210610/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5210610/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eLeft ventricular unloading is needed in patients on extracorporeal life support (ECLS) with severely reduced left ventricular contractility to avoid stasis and pulmonary congestion, and to promote LV recovery. The presence of thrombi in the LV precludes the use of conventional active unloading methods such as transaortic microaxial pumps or apical LV vents. We describe placement of a vent cannula via the left atrial appendage (LAA) as a useful bailout option.\u003c/p\u003e\u003ch2\u003eCase Presentation:\u003c/h2\u003e \u003cp\u003eA 61-year-old patient presenting with normotensive cardiogenic shock (SCAI C) after subacute anterior wall myocardial infarction deteriorated with pulmonary edema and ventricular fibrilation, requiring veno-arterial extracorporeal life support under ongoing CPR (SCAI E). An Impella CP was placed for LV unloading, but was unable to generate flow and removed. A large left ventricular thrombus was detected as the cause for insufficient Impella flow. For urgent LV unloading, we placed a vent cannula via the LAA through a thoracotomy to bridge our patient to total artificial heart implantation. However, intraoperative TEE showed resolution of the LV thrombus, enabling to change the strategy to left ventricular assist device implantation. Our patient made a full recovery and is now doing well in regular outpatient follow ups.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eECLS provides excellent circulatory support at the price of a high complication burden and considerable LV afterload increase. ECLS complications often require individualized solutions not represented in current HF guidelines. This patient has developed a dreaded and nearly always fatal ECLS complication, which was successfully managed with vent placement via the LAA.\u003c/p\u003e","manuscriptTitle":"Left atrial appendage cannulation for left ventricular unloading in a patient with ventricular thrombus on extracorporeal life support","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-12-01 16:49:46","doi":"10.21203/rs.3.rs-5210610/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-11-02T08:36:08+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-10-30T06:31:13+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-10-26T06:49:59+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"44604260804007907610648781359171545585","date":"2024-10-26T04:52:17+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-10-25T17:03:54+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-10-25T12:26:51+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-10-21T15:38:57+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"216462191054974067661159133730598177746","date":"2024-10-19T12:25:33+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"29518043055900003204412828983766941235","date":"2024-10-18T11:25:57+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"10073333129417590440590906283418639673","date":"2024-10-17T14:52:08+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"60804673911918681346418727393048681500","date":"2024-10-17T09:50:05+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"268081283416900794395832227921099734824","date":"2024-10-17T07:57:01+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"104119598454104993840314791161032253305","date":"2024-10-16T19:48:48+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"264082819218549865228781887404144677197","date":"2024-10-16T17:30:28+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-10-16T17:26:09+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-10-07T00:09:28+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-10-07T00:09:09+00:00","index":"","fulltext":""},{"type":"submitted","content":"Journal of Cardiothoracic Surgery","date":"2024-10-05T22:49:00+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"journal-of-cardiothoracic-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jcts","sideBox":"Learn more about [Journal of Cardiothoracic Surgery](http://cardiothoracicsurgery.biomedcentral.com)","snPcode":"13019","submissionUrl":"https://submission.nature.com/new-submission/13019/3","title":"Journal of Cardiothoracic Surgery","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"aa29983f-0008-49db-9865-d419c08933ff","owner":[],"postedDate":"December 1st, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-01-13T15:59:54+00:00","versionOfRecord":{"articleIdentity":"rs-5210610","link":"https://doi.org/10.1186/s13019-024-03288-4","journal":{"identity":"journal-of-cardiothoracic-surgery","isVorOnly":false,"title":"Journal of Cardiothoracic Surgery"},"publishedOn":"2025-01-10 15:57:05","publishedOnDateReadable":"January 10th, 2025"},"versionCreatedAt":"2024-12-01 16:49:46","video":"","vorDoi":"10.1186/s13019-024-03288-4","vorDoiUrl":"https://doi.org/10.1186/s13019-024-03288-4","workflowStages":[]},"version":"v1","identity":"rs-5210610","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5210610","identity":"rs-5210610","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}