Utilization of LA-VA ECMO to Support Implantation of a TAVR Valve in Torrential Aortic Regurgitation
Presenter
Kunal K. Chawla, MD, FSCAI, Optum, New Hyde Park, NY
Kunal K. Chawla, MD, FSCAI1, Sherif Labib, MD2, Sylwia Karpinski, MD3 and Thomas C. Piemonte, MD2, (1)Optum, New Hyde Park, NY, (2)Lahey Hospital and Medical Center, Burlington, MA, (3)Beth Israel Lahey Health, Burlington, MA
Title:
Utilization of LA-VA ECMO to Support Implantation of a TAVR Valve in Torrential Aortic Regurgitation
Introduction:
Extracorporeal Membranous Oxygenation (ECMO) may be used as mechanical support in patients with cardiogenic shock requiring a TAVR procedure. Our case surrounds a young patient in cardiogenic shock with torrential aortic regurgitation (AR). In these patients, traditional ECMO would be contraindicated due to increased afterload causing worsening backflow through the incompetent valve resulting in worsening LV dilation. We opted to perform Left Atrial Veno Arterial ECMO (LAVA ECMO) to support placement of a TAVR valve in an otherwise inoperable young patient.
Clinical Case:
A 42 YO male with past medical history significant for intravenous drug abuse, strep mitis endocarditis of the mitral valve in 2021 s/p mitral valve replacement (MVR), recurrent endocarditis in 2022 s/p redo MVR/tricuspid valve repair. He presented to the hospital a month after his MVR/tricuspid repair with decompensated heart failure and cardiogenic shock. Transesophageal echocardiography was revealing for perforation of the noncoronary cusp of the aortic valve resulting in severe AR. He was seen by the cardiac surgery service and was deemed a prohibitively high risk for surgical intervention. He remained in refractory cardiogenic shock. TAVR CT was revealing for a valve area of 649.9mm² without any calcium in the annulus or LVOT. Given this anatomy, TAVR would be high risk and there was concern for embolization of the valve during deployment and worsening shock from prolonged pacing/positioning during deployment. After extensive planning, it was decided that we would place an Edwards Sapien 29mm valve with plans to implant it on the mitral apparatus from his prior MVR. We opted to place our patient on LAVA ECMO to support his hemodynamics during the deployment. We obtained right femoral venous access and performed trans-septal puncture. We then placed a 24Fr catheter with a long 15cm fenestrated segment across the intra-atrial septum allowing intake from both the left and right atria. We obtained right femoral arterial access and placed a 19 Fr return cannula. Patient was placed on pump and we proceeded with the TAVR procedure from the right femoral artery. Using transesophageal echocardiography and angiographic guidance to position the valve in place, we deployed the valve under rapid pacing. Initial angiography showed the valve in place with attachment to the mitral apparatus however there was concern for torrential paravalvular leak and instability. Using the delivery balloon, we placed an additional 5cc of volume in the delivery syringe (total 38ml) and achieved further expansion of the valve with reduction of AR to the moderate-severe range. The patient improved in the days following his procedure, was weaned from inotropic support, and was eventually discharged home.
Discussion:
LAVA ECMO is a reasonable mechanical support device in patients with aortic insufficiency. Using this set up, we can support and oxygenate our patients in the same way as a traditional veno-arterial ECMO circuits but with the ability to unload the left sided chambers. This is an ideal choice for mechanical support in patients with severe AR.