Venoarterial Extracorporeal Membrane Oxygenation as a Bridge to Cardiac Recovery Following Right Ventricular Myocardial Infarction
Presenter
Madeline Smoot, MD, University of Florida College of Medicine Gainesville, Gainesville, FL
Madeline Smoot, MD1, Christopher Perry2 and Dhaval Naik2, (1)University of Florida College of Medicine Gainesville, Gainesville, FL, (2)University of Florida, Gainesville, FL
Title
Venoarterial Extracorporeal Membrane Oxygenation as a Bridge to Cardiac Recovery Following Right Ventricular Myocardial Infarction Introduction
Right ventricular myocardial ischemia (RVMI) and infarction remains an uncommon manifestation of acute coronary syndrome. We present a case of an inferior ST-segment elevation myocardial infarction (STEMI) with RVMI and concomitant left ventricular dysfunction, resulting in cardiogenic shock that required venoarterial extracorporeal membrane oxygenation (V-A ECMO) for complete cardiopulmonary support. Clinical Case
A 60-year-old man presented with stuttering chest pain, developed ventricular fibrillation leading to cardiac arrest. ECG showed sinus rhythm with 3mm ST-segment elevation of the inferior limb leads with reciprocal ST segment depression in V2-V6. Transradial coronary angiography showed occlusion at the ostium of the right coronary artery with only non-obstructive disease of the left coronary system. Percutaneous coronary intervention with balloon angioplasty and placement of a drug eluting stent within ostial RCA was performed. TIMI III flow was restored and OCT showed good stent apposition. LV ventriculogram showed EF 50% and LVEDP was 25 mmHg. Intra-procedure, the patient developed progressive cardiogenic shock requiring an intra-aortic balloon pump for mechanical support and escalation of vasopressor therapies. His hemodynamic requirements exceeded his active circulatory support with post-catheterization transthoracic echocardiography revealing severe LV dysfunction with EF of 10-15% and severe right ventricular dilation. Thus V-A ECMO via central cannulation for complete cardiopulmonary support was initiated within four hours of re-vascularization. Transthoracic echocardiogram one week later demonstrated recovery of biventricular function and the patient was eventually decannulated. He was discharged and did well with clinic follow-up. Discussion
The benefit of V-A ECMO as temporary mechanical support in acute myocardial infarction complicated by cardiogenic shock is not well defined due to the observational nature and diverse populations included in prior studies. A literature review showed that in a single center at 12 months after weaning from V-A ECMO for cardiogenic shock, 65% of patients remained alive. We elected to proceed with V-A ECMO implementation. V-A ECMO is becoming increasingly popular as a bridge-to-recovery approach in this subset of patients. This case highlights the successful implementation of V-A ECMO in post-acute myocardial infarction and cardiogenic shock.