Considerations on Enhancing Venoarterial-Extracorporeal Membrane Oxygenation Via Transapical Cannulation and Minimally Invasive Techniques

To the Editor: I would like to extend my heartfelt congratulations to the authors Cappelli et al.1 for their outstanding article published in the ASAIO Journal, titled “Direct Apical Cannulation with Protek Duo Rapid Deployment Cannula via Mini Thoracotomy for Ambulatory Venoarterial-Extracorporeal Membrane Oxygenation.” The transapical placement of the Protek Duo cannula offers numerous advantages, including the avoidance of complications associated with peripheral arterial access and enabling early patient mobilization. Moreover, the transapical approach facilitates reduced cannula resistance, thereby enhancing blood flow efficiency and further minimizing complication risks. These benefits are critical in improving clinical outcomes and the quality of life for patients suffering from cardiogenic shock.1 In relation to patient mobility, I would like to propose the consideration of intelligent systems that could adapt the pump flows and speeds during the transition from supine to upright positions. Such systems could monitor real-time vital parameters and automatically adjust extracorporeal membrane oxygenation (ECMO) flows, ensuring optimal support and reducing the risk of complications during mobilization.2 This innovative approach could further enhance the safety and efficacy of the therapy, allowing patients to fully benefit from early mobilization. Additionally, I am curious if the authors have considered the endoscopic or robot-assisted surgical approach as a viable alternative for the placement of the Protek Duo cannula. Utilizing minimally invasive techniques such as these could further reduce the invasiveness of the procedure, minimize surgical trauma and adhesions, and improve postoperative recovery. Specifically, endoscopic and robot-assisted approaches could lower the incidence of surgical site infections due to smaller incisions and greater precision in tissue handling.3 It is also important to note that the rapid deployment aspect of the implant is not sacrificed with the endoscopic approach, as the speed largely depends on the team’s technical skills and the learning curve. I would be interested in hearing the authors’ perspectives on these possibilities and whether they believe these approaches could be explored in future studies. I appreciate the opportunity to contribute to this discussion and am available for further elaboration and collaboration.