Tricky papillary muscle rupture sequelae navigated by evidence-based therapies using ECMO and Impella

Abstract

This case illustrates an atypical mitral valve prolapse presentation with superimposed stress of acute respiratory distress syndrome (ARDS) as well as the importance of extracorporeal membrane oxygenation therapy (ECMO) as a bridge to definitive surgical intervention. Switching from venovenous (VV) to venoarterial (VA) ECMO allowed bypass of the pulmonary circulation and provided cardiac support to assist in systemic circulation in the setting of severe mitral regurgitation with mitral valve prolapse. However, VA ECMO increases afterload, thus an Impella was used to offload the left ventricle and provide forward flow. Relying on evidence-based medicine for each modality despite its complexity also optimized this patient’s chance for recovery. Thereby, we demonstrate a complex case of ARDS, mitral valve prolapse secondary to myocardial infarction, and subsequent multiple arrhythmic arrests, where successful VV and VA ECMO resuscitation afforded bridge therapy to definitive surgical management. Our patient showed promising results, and we would like to encourage this strategy to bridge patients requiring surgical intervention.