Catheterization and Cardiovascular Interventions 85:1097–1099 (2015)

Percutaneous Bi-atrial Extracorporeal Membrane Oxygenation for Acute Circulatory Support in Advanced Heart Failure Marwan Jumean, MD, Duc Thinh Pham, MD, and Navin K. Kapur,* MD Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) may improve survival after cardiac arrest by providing cardiopulmonary support. However, VA-ECMO increases left ventricular (LV) afterload, which can promote progressive LV distension and often requires a secondary approach to reduce LV pressure and volume in patients with left heart failure. We report a case of biventricular unloading via biatrial cannulation in the presence of LV thrombus using a TandemHeart percutaneous trans-septal cannula for VAECMO in an adult patient with refractory ventricular fibrillation. VC 2015 Wiley Periodicals, Inc. Key words: heart failure; mechanical circulatory support; ECMO/IABP/Tandem/Impella; shock; cardiogenic; ventricular assist device

INTRODUCTION

Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) use has been increasingly utilized in recent years in rapidly providing full biventricular support in patients with cardiogenic shock with biventricular failure. However, VA-ECMO can potentially lead to progressive left ventricular (LV) distention that requires a secondary “venting” approach. Several venting strategies have been reported in the past. We report a novel venting approach with biatrial decompression via percutaneous trans-septal left atrium (LA) drainage using a TandemHeart trans-septal cannula in an adult with refractory ventricular arrhythmias. CASE

A 30 year-old man with non-insulin dependent diabetes mellitus presented with six weeks of progressive fatigue, dyspnea on exertion, orthopnea, and paroxysms of nocturnal dyspnea. Prior medical history included nephrotic syndrome and a remote, unprovoked pulmonary embolic event. Initial evaluation revealed severe left ventricular systolic dysfunction and an apical aneurysm with a layered left ventricular thrombus (Fig. 1A; Supporting Information Video 1). Cardiac catheterization identified an extensive, organized thrombus in the proximal left anterior descending artery (LAD) (Fig. 1B; Supporting Information Video 2), elevated right and left filling pressures, and reduced cardiac output. Given the late presentation of this anterior infarct and aneurysmal apex, no intervention was performed on the LAD. Low dose milrinone and a continuous furosemide infusion optimized his hemodynamic status for C 2015 Wiley Periodicals, Inc. V

72 hr before transitioning to oral medications only. On hospital day 5, the patient was asymptomatic when he developed refractory ventricular fibrillation. Emergent VA-ECMO was initiated with a 24-French (Fr) multistage venous cannula and a 17-Fr arterial cannula in the right femoral vein and artery. Despite flows of 4.5 liters per minute (LPM), left heart filling pressures increased on VA-ECMO support, transesophageal echocardiography (TEE) confirmed LV distention (Supporting Information Video 3), and recurrent ventricular arrhythmias persisted. To decompress the LV, a 21-Fr TandemHeart trans-septal cannula (CardiacAssist) was inserted into the LA using fluoroscopic guidance only via the left femoral vein and attached to the inflow segment of the centrifugal pump (Thoratec Inc) using a 3/800 Yconnector (Fig. 2A and B). Hemodynamics showed reduced biventricular filling pressures and TEE confirmed biventricular unloading (Supporting Information Video 4) with resolution of refractory ventricular arrhythmias. After 48 hr of uncomplicated VA-ECMO support, The Cardiovascular Center, Tufts Medical Center, Boston, Massachusetts Additional Supporting Information may be found in the online version of this article. *Correspondence to: Navin K. Kapur, MD, The Cardiovascular Center, Tufts Medical Center, 800 Washington Street, Box # 80, Boston, MA 02111. E-mail: [email protected] Received 25 August 2014; Revision accepted 14 December 2014 DOI: 10.1002/ccd.25791 Published online 13 January 2015 in Wiley Online Library (wileyonlinelibrary.com)

1098

Jumean et al.

the patient underwent placement of a left ventricular assist device (LVAD) as a bridge to transplantation (Fig. 2C). Two weeks after surgery, the patient developed a de novo thrombus involving the right atrium and ventricle requiring thrombectomy and placement of a temporary RVAD. Two days later he developed refractory cardiogenic shock and expired. DISCUSSION

We report a case of advanced left heart failure complicated by refractory ventricular arrhythmias requiring initiation of emergent VA-ECMO using a percutaneous biatrial cannulation technique. This is the first report to describe successful transition from bi-atrial ECMO using the TandemHeart trans-septal cannula for advanced heart failure and ventricular arrhythmias to continuous flow LV support using the HeartWare HVAD. Our report highlights the potential importance of bi-atrial cannulation as a temporary biventricular support strategy to transition critically ill patients to durable mechanical support. In this case, a prothrom-

Fig. 1. A: Admission echocardiogram showing a dilated left ventricle with an apical thrombus (†). B: Coronary angiogram showing a thrombotically occluded proximal left anterior descending artery (*). [Color figure can be viewed in the online issue, which is available at wileyonlinelibrary.com.]

botic substrate likely contributed to his initial presentation with ischemic cardiomyopathy and subsequent RV thrombosis. VA-ECMO via peripheral cannulation is an important acute circulatory support strategy for patients with cardio-respiratory arrest, biventricular failure, refractory ventricular arrhythmias, or who are too unstable to transport to the operating room or fluoroscopic laboratory. By displacing blood volume from the venous to arterial system, VA-ECMO reduces biventricular preload. However, to achieve significant LV unloading in the setting of profound venous congestion, more blood volume needs to be displaced from the venous to arterial system. As a result of increased flow, the arterial system becomes increasingly pressurized and LV afterload increases. Various approaches to reducing LV afterload while on concomitant VA-ECMO support have been proposed and include LV mechanical assist, pharmacologic support, atrial septostomy, or alternative cannulation techniques (Table I) [1–4]. In this case, trans-septal LA cannulation was chosen due to the need for active decompression of the LV and the presence of a LV thrombus, which precluded use of atrial septostomy alone as a passive LV unloading mechanism or an emergent, direct LV approach (surgical or percutaneous). Another potential advantage of biatrial cannulation using this approach is the ability to de-escalate biventricular support in stepwise fashion by first removing the RA cannula and leaving the patient on LA-Femoral artery (FA) bypass to support the LV alone. To our knowledge, this is the first report describing biatrial decompression via percutaneous TandemHeart trans-septal LA drainage cannula in an adult with refractory ventricular arrhythmias and successful transition to a durable continuous flow LVAD.

Fig. 2. Biatrial veno-arterial extracorporeal membrane oxygenation. A: Illustration of biatrialECMO circuit. B: Y-connector showing right (RA) and left (LA) atrial inflow. C: Radiograph showing final inflow cannula positioning. [Color figure can be viewed in the online issue, which is available at wileyonlinelibrary.com.] Catheterization and Cardiovascular Interventions DOI 10.1002/ccd. Published on behalf of The Society for Cardiovascular Angiography and Interventions (SCAI).

Percutaneous Bi-atrial ECMO TABLE I. Left Heart Decompression Strategies Left heart decompression strategies during VA-ECMO Percutaneous

Surgical

Noninvasive

Intra-aortic balloon pump Impella axial flow catheter Trans-septal LV cannulation Trans-septal LA cannulation Atrial septostomy Pulmonary artery cannulation Direct LV apical cannulation Direct LA cannulation Central cannulation ECMO Inotropic support Reducing VA-ECMO flow

CONCLUSION

Bi-atrial ECMO cannulation is a feasible acute support strategy for biventricular failure as a bridge to durable mechanical support, recovery, or cardiac trans-

1099

plantation. Further studies assessing the ideal venting strategy in VA-ECMO patients are needed. REFERENCES 1. Aiyagari RM, Rocchini AP, Remenapp RT, Graziano JN. Decompres-sion of the left atrium during extracorporeal membrane oxygenation using a transseptal cannula incorporated into the circuit. Crit Care Med 2006;34:2603–2606. 2. Kang, MH, Hahn JY, Gwon HC, Song YB, et al. Percutaneous transseptal left atrial drainage for decompression of the left heart in an adult patient during percutaneous cardiopulmonary support. Korean Circ J 2011; 41:402–404 3. Cheung MM, Goldman AP, Shekerdemian LS, Brown KL, Cohen GA, Redington AN. Percutaneous left ventricular “vent” insertion for left heart decompression during extracorporeal membrane oxygenation. Pediatr Crit Care Med 2003;4:447–449. 4. Hlavacek AM, Atz AM, Bradley SM, Bandisode VM. Left atrial decompression by percutaneous cannula placement while on extracorporeal membrane oxygenation. J Thorac Cardiovasc Surg 2005;130:595–596.

Catheterization and Cardiovascular Interventions DOI 10.1002/ccd. Published on behalf of The Society for Cardiovascular Angiography and Interventions (SCAI).

Percutaneous bi-atrial extracorporeal membrane oxygenation for acute circulatory support in advanced heart failure.

Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) may improve survival after cardiac arrest by providing cardiopulmonary support. However, V...
159KB Sizes 0 Downloads 8 Views