Successful weaning from veno-arterial ECMO and Impella2.5 by veno-venous and arterial ECMO (v-ECPELLA) for a patient with acute myocardial infarction complicated by severe lung injury

Abstract

The Impella™ (Abiomed, Danvers, MA, USA) is a percutaneous left ventricular assist device and is concurrently used with veno-arterial extracorporeal membrane oxygenation (VA ECMO). However, concomitantly using these two devices makes identifying the mixed zone of two opposite blood flows difficult. We report the case of an 80-year-old man with ST-elevation myocardial infarction and cardiopulmonary arrest. Emergent coronary angiography showed 99% stenosis in the left main trunk. A drug-eluting stent was placed under support of VA ECMO and the Impella2.5 for cardiogenic shock. During this support, antegrade deoxygenated blood enhanced by the Impella was sent to the right radial artery. Inadequate oxygenated blood was delivered through the native lung, which was damaged by cardiopulmonary resuscitation. We decided to convert to veno-venous and arterial ECMO (V-VA ECMO) using additional venous cannulation as drainage. Returned oxygenated blood was sent to the inferior vena cava and femoral artery bilaterally for maintaining oxygenation in the pulmonary artery. In V-VA ECMO and the Impella (v-ECPELLA), we attempted weaning from VA ECMO by only clamping VA cannulation and switching to veno-venous ECMO. We restored the setting to VA ECMO after assessment of the systemic circulation. We successfully managed and weaned our patient from simultaneous use of VA ECMO and the Impella2.5 by using v-ECPELLA.<Learning objective: Simultaneous use of the Impella and veno-arterial extracorporeal membrane oxygenation (VA ECMO) is sometimes required in cases with severe lung injury. However, using these two devices may increase unexpected perfusion of unoxygenated blood in the coronary and cerebral arts. Veno-venous and arterial ECMO with the Impella can reduce the risk of hypoxia because of returned oxygenated blood to the inferior vena cava. This method might be useful for maintaining and weaning from simultaneous use of VA ECMO and the Impella.>