EXTRACORPOREAL MEMBRANE OXYGENATION WITH BI-ATRIAL UNLOADING TO TREAT BIVENTRICULAR DYSFUNCTION
Singh-Kucukarslan G, Raad M, Al-Darzi W, Cowger J, Brice L, Basir M, O'Neill W, Alaswaad K, and Eng M. EXTRACORPOREAL MEMBRANE OXYGENATION WITH BI-ATRIAL UNLOADING TO TREAT BIVENTRICULAR DYSFUNCTION. Journal of the American College of Cardiology 2021; 77(18):2382.
Journal of the American College of Cardiology
Background: Veno-arterial extracorporeal membrane deoxygenation (ECMO) is increasingly used in patients with cardiogenic shock and myocardial injury.
Case: A 59-year old male with a history of coronary artery bypass graft presented with a lateral ST-elevation myocardial infarction. He received thrombolytics however had persistent ST elevations requiring angiography, and a salvage-percutaneous intervention was performed. Despite successful angioplasty, he spiraled into cardiogenic shock prompting placement of a transfemoral Impella CP, after which he was transferred to our center. Echocardiogram revealed a left ventricular ejection fraction of 25%, moderate right ventricular dysfunction, and severe mitral regurgitation with frequent ventricular tachycardia requiring cardioversion.
Decision-making: He was in cardiogenic shock SCAI stage D. With maximal impella support, his kidney, liver enzyme, and lactate levels were within normal limits. The ventricular tachycardia became less frequent. However, given his progressively increasing pulmonary artery (PA) pressures, increasing vasopressor requirements, and borderline low cardiac index, the decision was to upgrade his hemodynamic support. A left atrial veno-arterial (LAVA) cannulation strategy was considered for additional left ventricular offloading given his biventricular dysfunction and severe mitral regurgitation. Intracardiac echocardiography was used to guide balloon septostomy and placement of an Edwards Lifesciences VFEM024 24Fr cannula that traversed both left and right atria. The Impella CP was exchanged for a 19Fr arterial cannula. Immediately after cannulation, his mean PA pressure decreased from 38 to 25 mmHg, and cardiac index increased from 2 L/min/m2 to 5-6 L/min/m2. Despite improved hemodynamics, he was unable to be weaned from LAVA ECMO. He underwent orthotopic heart transplantation 11 days post-cannulation.
Conclusion: This case demonstrates the benefits of early hemodynamic support with a LAVA cannulation strategy. LAVA is a safe and viable option that offers ECMO support with additional left ventricular offloading using a single inflow cannula.