PRESENTATION OF CASE

A 73-year-old patient suffered cardiac arrest during surgical placement of a hemodialysis catheter. The clinical history included coronary artery disease with a left ventricular (LV) ejection fraction of 29%. After initially successful cardiopulmonary resuscitation (CPR), the patient developed a refractory Cardiogenic shock (CS), leading the treating physicians to ask for VA-ECMO assisted transfer to our hospital. Upon arrival of our shock team, cannulation for the VA-ECMO was done under ongoing CPR. The patient was subsequently transferred to our hospital under VA-ECMO support. 

The TTE assessment after successful cardiac defibrillation showed no residual LV contractile function. Emergent coronary angiography revealed a severe distal in-stent thrombosis of the LAD, requiring PTA. Furthermore, a higrade stenosis of the medial LCX was treated with a DES (Figure 1). The patient had an aortic regurgitation resulting in constant retrograde blood-flow into the LV under ECMO support. Intracardiac hemodynamic measurements revealed a massively increased LVEDP of 65 mmHg. For unloading of the LV, a percutaneous transvalvular micro-axial flow pump (Impella CP) was placed in the LV. Under maximal support power, the LVEDP rapidly decreased. However, due to VA-shunting by the ECMO, filling of the LV was lower than the venting volume provided by the Impella resulting in insufficient LV filling. Decreasing the Impella support power to P3 balanced in- and out-flow as shown in the LV pressure tracing (Figure 2). 

During the next 12 hours, pulmonary ventilation decreased to <3.0ml/kg/min. Additionally, pulmonary blood flow decreased as detected in TTE/TEE and via pulmonary artery catheter. The CT assessment showed a severe pulmonary deterioration with progressive consolidations, as compared to the previous day. The echocardiographic assessment revealed a severe right ventricular failure. An additional right-sided axial flow pump (Impella RP) was positioned in the pulmonary trunk, unloadinvig the right ventricle. To ensure oxygenated blood supply to the pulmonary circulation, a second outlet cannula was connected to the arterial line of the ECMO and placed in the right internal jugular vein (VAV-ECMO). Subsequently an immediate cardiac improvement with significantly decreasing right ventricular dimensions was achieved (Figure 3). Moreover, a rapidly improved ventilation and gas-exchange could be observed.

In the next days, the clinical situation improved, allowing reduction of the inotropic therapy. On day six, explantation of the VAV-ECMO was performed. However, weaning from the axial flow pump was prolonged. Flow rates of the axial flow pumps were gradually reduced, as the left and right ventricular function constantly improved, until the right sided Impella RP could be successfully explanted. Another five days later, the LV Impella CP was removed. The TTE assessment revealed a moderately reduced LV ejection fraction of 40% and a normal right ventricular function. 

Unfortunately, on the day of planed discharge, the patient developed therapy-refractory ventricular fibrillation. The emergent coronary angiography revealed adequate blood flow in the coronary arteries. Despite additional high-dose inotropic therapy and further defibrillations, a return of spontaneous circulation could not be achieved. In view of the overall situation of the patient with a prolonged and severe course of the disease, the CPR was terminated.

Fig 1


Fig 2


Fig 3