Clin Res Cardiol (2023). https://doi.org/10.1007/s00392-023-02180-w
Extracorporeal membrane oxygenation and valve in valve transcatheter aortic valve implantation in a young patient with prosthetic valve restenosis and severe cardiogenic shock
T. Nowack1, J. Mierke1, A. Linke1, N. Mangner1
1Klinik für Innere Medizin, Kardiologie und Intensivmedizin, Herzzentrum Dresden GmbH an der TU Dresden, Dresden;

A 34-year-old female patient presented urgently to our hospital complaining dyspnea and progressive lower extremity edema. Eleven years ago a 32 mm Perimount prosthesis was implanted because of severe aortic stenosis. Two months ago, she had delivered a child by cesarean. During pregnancy surveillance aortic restenosis was diagnosed.
Patient was in severely reduced general condition, evidenced orthopnea, massive low extremity edema, pulmonary rales and alternated cerebral status. Body temperature of 38.3 °C, blood pressure 100/63 mmHg with sinus tachycardia of 108/min and a systolic murmur.

Lab testing found elevated wbc 28 Gpt/l and CRP 91.5 mg/l, acute liver damage (ALAT 43.3 ASAT 35.4 µkat/l) with altered coagulation (INR: no coagulation, pTT 53.3s, D-Dimer 35.5 mg/l, fibrinogen below detection boundary), low platelets (88 Gpt/l) and acute renal failure (creatinin 110 µmol/l, urea 18.6 mmol/l), severe lactate acidosis (12.5 mmol/l). Sodium of 128 mmol/l and potassium 6.47 mmol/l.
Echocardiography revealed high pressure gradients over the prosthetic aortic valve of 77/53 mmHg and opening valve area was calculated with of 0.3 cm2. Left ventricular function was severely reduced to 23% and left ventricular apical thrombus was seen.
The Patient was transferred to the ICU. Empirical antibiotic treatment was started with piperacillin-tazobactam. Central venous oxygenation was below 40%, so enoximone therapy was initiated. Because of high potassium dialysis was started but was complicated by recurrent filter clotting despite pTT even above target range. Transesophageal echocardiography found no evidence for endocarditis. CT scan showed atypical bipulmonal pneumotic infiltrations and ruled out coronary artery disease.
After initial stabilization hemodynamics became unstable. Need of catecholamines and lactate raised rapidly, urinary excretion ebbed. Patient was found in functional inoperability indicated by EURO Score II of 70,21% perioperative mortality. Decision of salvage transcatheter aortic valve implantation was made. But patient collapsed before procedure started and short cardiopulmonary reanimation was needed. Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) was implanted at bedside and subsequently TAVI procedure was completed by implanting EdwardSapiens 3 ultra 23mm over the right groin. Arterial cannulation site at groin showed persisting bleeding and antegrade puncturing failed. So access was transferred to the right side using plug based vascular closing system for left femoral access. After procedure transvalvular gradients could be reduced to 30/17 mmHg. Patient showed polymorphic ventricular tachycardia which were tolerated under ECMO support and could be treated sufficiently with lidocaine and amiodarone. ECMO and respirator could be weaned over next few days.

Patient showed acral necroses at toes of both sides which where seen consecutive to shock and need for catecholamines. To rule out macrovascular obstruction CT angiography was done and revealed complete occlusion of left common femoral artery due to plug based vascular closing system. Patient showed no deficit neither in motor function nor sensibility so elective surgical revascularization were done.

Follow up as oupatient up to 6 months showed fully recovered patient complaining no impediment in daily life, left ventricular function recovered to 60 percent with transvalvular pressure of 48/27 mmHg. Left ventricular thrombus completely resolved.
https://dgk.org/kongress_programme/jt2023/aV1620.html