Incessant Ventricular Tachycardia and Cardiogenic Shock: VA-ECMO as Bridge to Recovery
Presenter
Auras R. Atreya, MD, MPH, FACC, FHRS, AIG Hospitals, Little Rock, AR
Auras R. Atreya, MD, MPH, FACC, FHRS1, Vijay Shekar, MD, DM, FSCAI2, Naresh Kumar, MS, MCH3, Aman Enayati, MD3, Karthik Mikkineni, MD, FACVS3, Sukesh K Reddy, MS, MCH3, Rajeev V. Menon, M.D., FSCAI4 and Calambur Narasimhan, MD, DM3, (1)AIG Hospitals, Little Rock, AR, (2)Kauvery Heart City, Tiruchirappalli, Tamil Nadu, India, (3)AIG Institute of Cardiac Sciences and Research, Hyderabad, --, India, (4)Centrix Healthcare, Hyderabad, --, India
Title
Incessant Ventricular Tachycardia and Cardiogenic Shock: VA-ECMO as Bridge to Recovery Introduction
Cardiogenic shock (CS) of any cause portends a poor prognosis and often needs temporary mechanical circulatory support (TMCS) for bailout.
Clinical Case
A 34-year-old male with history of ACC/AHA Stage C idiopathic, non-ischemic cardiomyopathy and prior ventricular tachycardia (VT) storm status post bilateral surgical sympathetic denervation and a single chamber ICD presented with ventricular tachycardia and SCAI Stage B CS. Device interrogation revealed continuous VT at 160 bpm for the past 50 hours that was below the programmed ICD VT therapy zone (182 bpm). The patient was sedated and cardioverted after which he progressed to SCAI Stage C CS that required IABP placement along with Swan-Ganz catheter placement to monitor hemodynamics. Due to worsening Stage D CS (Cardiac Index 1.7 L/min/m2) despite IABP and multiple inotropes, a decision was made to pursue TMCS as bridge to recovery vs. advanced therapy. Available TMCS options in India include Impella 5.0 vs. Peripheral VA-ECMO. ECMO was pursued due to lower cost than Impella and immediate availability. Vascular access was obtained using ultrasound and micropuncture kit in the Cardiac Cath lab and percutaneous peripheral V-A ECMO cannulation was done using a 24 French multistage inflow cannula placed in SVC-RA-IVC via the right femoral vein and an 18 French outflow cannula placed in the right femoral artery. To prevent distal right limb ischemia, a 7 French antegrade superficial femoral artery sheath was placed and perfused simultaneously from the outflow cannula. A RotaFlow (
Maquet, Getinge Group) centrifugal pump was used. The previously placed IABP via left femoral artery was left in placed to serve to unload the left ventricle. No further VT was noted on amiodarone and lidocaine and emergent VT ablation was not pursued. The patient was simultaneously listed for an emergent heart transplant. In the cardiac intensive care, the patient required continuous renal replacement therapy (CRRT) due to lack of renal recovery. Hemodynamic monitoring was done multiple times daily using the thermodilution Swan-Ganz catheter and ECMO flows were maintained above 4L/min. A left pleural effusion developed requiring a chest tube and multiple blood products were needed to maintain hemoglobin and platelet count. Eventually, ECMO decannulation was done surgically in the operating room (12 days) and the IABP was removed 2 days later. The patient made a slow recovery, requiring intermittent hemodialysis. He was also treated for a ventilator assisted pneumonia and then extubated. Remarkably, he had renal recovery, and came off dialysis and after inpatient cardiac rehabilitation, the patient was discharged home on betablockers and anti-arrhythmic agents after 32 days. He has remained free of VT and resumed NYHA II functional status over the past 4 months. He has been taken off the transplant list and his ICD is being remotely monitored for any arrhythmia recurrence, in which case VT ablation will be offered to prevent another decompensation.
Discussion
Refractory CS secondary to ventricular arrhythmias often need TMCS and emergent VT ablation. In this case, VT was quiesced with anti-arrhythmics, general anesthesia and TMCS with VA-ECMO.