Quick Action is the Ticket to a New Life: Appropriate Recognition and Response with VA ECMO Use for Primary Graft Dysfunction

Abstract

Introduction Primary graft dysfunction (PGD) is a dreaded complication in heart transplant patients. Several risk factors have been associated with PGD with recent recognition of amiodarone use contributing significantly to severe PGD. While overall incidence can be relatively low, the mortality for PGD approaches up to 40%. Case Report A 67 yo male with NICM (EF 10-15%), CRT-D implant in 2015, and HVAD as BTT in 5/2019 due to VT and cardiogenic shock presented with sudden nausea, diaphoresis, and subsequently received several consecutive shocks from his CRT-D. He was found to be in VT/VF storm despite multiple device shocks and dofetilide and mexilitine therapy. Device interrogation later revealed that the defibrillation threshold was higher than before and that he had received 2 rounds of ATP degenerating VT into VF and then received 8 41J shocks, all unsuccessful in converting his rhythm. He was trialed on lidocaine infusion without effect and then received external cardioversion with initiation of amiodarone infusion. Patient was progressing well but had recurrent slow VT while hospitalized. This episode required 3 rounds of ATP and required re-initiation of amiodarone infusion despite dual oral anti-arrhythmic therapy. He was upgraded to UNOS status 2 and underwent orthotopic heart transplant during the hospitalization. While in the OR, patient was quickly recognized to have mild-moderate PGD thought to be secondary to the necessary amiodarone. From prior experience, it was decided to place patient on VA ECMO circuit while in the OR rather than maintain inotropic therapy despite limited use of MCS outside of severe PGD. He remained on minimal VA ECMO support for a few days and was transitioned onto inotropic therapy. The patient did well through the remainder of the hospitalization and was discharged several weeks later with fully recovered cardiac function. Summary This case displays that prompt recognition of PGD and early initiation of MCS therapies like VA ECMO might be prudent for patient survival. With cardiac transplants increasing nationally, it is important to be cognizant of risk factors for PGD including recent amiodarone use as a risk factor. The decision to use VA ECMO early allowed us to be prepared for worsening graft function and provide optimal support early if needed rather than await an emergent situation which has known poor patient outcomes.