Left ventricular decompression on Veno-arterial extracorporeal membrane oxygenation with intra-aortic balloon Counterpulsation

Jan M Griffin,Arthur R Garan,Koji Takeda,Susan Restaino

doi:10.1186/s13019-019-0970-3

Abstract

BackgroundVeno-arterial extracorporeal membrane oxygenation (VA-ECMO) has been used increasingly to support patients with cardiogenic shock (CS). There has been growing recognition of the favorable and unfavorable hemodynamic effects of this therapy and recent interest in the use of other percutaneous circulatory support devices to offset some of the potentially harmful hemodynamic effects. Herein, we provide visual evidence of the effects of intra-aortic balloon pump (IABP) counterpulsation for a patient with peripheral VA-ECMO cannulation.Case presentationA 68 year old man who had undergone orthotopic heart transplantation presented with 2 days of fatigue, orthopnea, and paroxysmal nocturnal dyspnea. On examination, he was tachycardic, hypotensive and hypoxic with cool extremities, consistent with CS. Transthoracic echocardiogram (TTE) showed new severe biventricular dysfunction with a left ventricular ejection fraction of 15%, right heart catheterization demonstrated elevated filling pressures and low output. An IABP was inserted via the left femoral artery with minimal improvement in hemodynamics. He was escalated to VA-ECMO. Repeat TTE demonstrated aortic valve (AV) opening with each cardiac cycle and mild MR. With placement of the IABP on standby Additional file 1: Video 1 (video 0:03), the AV no longer opened. Re-initiation of balloon counterpulsation resulted in resumed AV opening with each beat Additional file 1: Video 1 (video 0:17). He was treated for presumed acute allograft rejection with methylprednisolone, thymoglobulin, intravenous immunoglobulin and plasmapheresis with improvement in allograft function. However, he developed an Enterobacter aerogenes pneumonia and rapidly fatal septic shock.ConclusionsThis case visually demonstrates effective LV decompression by IABP counterpulsation in VA-ECMO support. While the overall effects of LV decompression in patients on VA-ECMO with IABP are still unclear, this report demonstrates one potential mechanism of benefit in the prevention of stagnation of blood flow that may lead to intra-cardiac or aortic root thrombus formation.

Highlights

Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) has been used increasingly to support patients with cardiogenic shock (CS)
Pressure (LVEDP) and left ventricle (LV) distension (LVD) which may be associated with impaired myocardial recovery or other signs of LV pressure overload such as ventricular arrhythmia, pulmonary edema or intracardiac thrombus formation [2, 3]
Transthoracic echocardiogram (TTE) showed new severe biventricular dysfunction with LV ejection fraction of 15%. He was brought to the cardiac catheterization lab for endomyocardial biopsy and right heart catheterization (RHC) which demonstrated elevated filling pressures (right atrial pressure (RAP) 22 mmHg, mean pulmonary artery pressure 33 mmHg, pulmonary capillary wedge pressure (PCWP) 36 mmHg, pulmonary artery saturation (PA sat) 43%, and Fick cardiac index 1.5 L/min/m2)