Title
Left Atrial Veno-Arterial (LAVA) ECMO for Cardiogenic Shock and Acute Aortic Regurgitation as a Bridge to Valve-in-Valve TAVR and PCI
Introduction
Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) provides biventricular support and can be a life-saving procedure in patients presenting with cardiogenic shock. However, there is a well-established negative effect on left-sided loading parameters given the increase in afterload, which can be especially detrimental in patients with concomitant severe aortic regurgitation. LAVA-ECMO is a modality that should be considered in these situations when acute LV unloading is also required.
Clinical Case
A man (51yrs) with history of infective endocarditis requiring surgical aortic valve replacement in 2012 with a Freestyle 23 mm bioprosthesis (Medtronic, Dublin, Ireland) and a root repair presented to an outside institution with acute chest pain and shortness of breath at rest. His systemic BP was 80/30 (mean 37) mm Hg and on physical examination he was found to have a grade 4 systolic murmur with a diastolic component. Electrocardiogram showed no localizing ST-segment elevation and laboratory profile was remarkable for a high-sensitivity troponin I of 5.6 ng/dL. An urgent transthoracic echocardiogram revealed a severely depressed LV ejection fraction and significant structural valve degeneration of the bioprosthetic valve causing mixed valve disease with severe aortic stenosis and aortic regurgitation. A left heart catheterization was performed which elicited severe 3-vessel CAD involving the left main and an LVEDP of 35 mmHg. Right heart catheterization was also performed revealing severely elevated right heart filling pressures (RA 22 mmHg) and left heart filling pressures (PCW 38 mmHg), cardiac index 0.96 L/min/m
2, and an aortic valve area 0.53 m
2 (peak-to-peak gradient 25 mmHg). A 50 cc intra-aortic balloon pump was placed and vasopressors were escalated to high doses of norepinephrine and dobutamine. The patient continued to deteriorate, he was transferred to Henry Ford hospital for escalation of care. The SHD and shock teams evaluated the patient. He was deemed not an appropriate surgical candidate given his multiple comorbidities including end-stage renal disease, sick sinus syndrome status post pacemaker, and obstructive sleep apnea. Proceeded with LAVA-ECMO, instead of traditional VA-ECMO, as a bridged to definitive therapy with ViV TAVR and PCI. With this modality, the venous cannula is placed in the transseptal position allowing for biatrial drainage and left ventricular unloading. The procedure was performed with moderate anesthesia care in order to avoid the detrimental effects of general anesthesia in a critically-ill patient. Invasive hemodynamics 30 minutes after the procedure demonstrated that the LVEDP dropped to 16 mmHg, RA pressure dropped to 8 mmHg, and CI increased to 3.2 L/min/m
2. The patient improved clinically over the next 48 hours and underwent an uncomplicated ViV TAVR with a Sapien 23 mm and PCI with rotational atherectomy and placement of a drug-eluting stent from the left main into the LAD. Repeat TTE demonstrated a dramatic improvement in LV function and trace PVL. The patient was discharged.
Discussion
This case demonstrates that LAVA-ECMO is a viable option to provide systemic hemodynamic support and adequate left ventricular unloading in these complex clinical scenarios.