Successful Peripheral Percutaneous Veno-arterial Extracorporeal Membrane Oxygenation Assisted High-risk Percutaneous Coronary Intervention in the Setting of Biventricular Dysfunction
Presenter
Masi Javeed, MD, HCA Florida Bayonet Point Hospital, Hudson, FL
Masi Javeed, MD, Hanan Gruhonjic, MD, Justin Goh, MD, Neha Patel, MD, Vinod Raxwal, MD, Khaja Zaki, MD and Rami Akel, MD, HCA Florida Bayonet Point Hospital, Hudson, FL
Title
Successful Peripheral Percutaneous Veno-arterial Extracorporeal Membrane Oxygenation Assisted High-risk Percutaneous Coronary Intervention in the Setting of Biventricular Dysfunction Introduction
For patients with severe CAD who are not suitable for CABG, high-risk PCI is a feasible option. In the setting of LV dysfunction, MCS may be required during high-risk PCI. Current types of MCS include IABP, Impella, TandemHeart, and VA-ECMO. A limitation of a majority of the aforementioned devices is that they are mainly for unilateral ventricular support. In addition, guidelines do not clearly elucidate the optimal choice of MCS for high-risk PCI in patients with biventricular dysfunction. In this report, we describe the case of a patient who successfully underwent high-risk PCI with peripheral percutaneous VA-ECMO support in the setting of significant biventricular dysfunction. Clinical Case
73M, with PMH including HFrEF with AICD, persistent AFib, OSA, COPD with tobacco use, agent orange exposure, T2DM, HTN, and HLD, was admitted for one month of SOB, edema, dry cough, and fatigue. Vitals revealed hypotension. Physical exam revealed bilateral crackles and reduced bibasilar lung sounds, JVD, cardiac ascites, and bilateral lower extremity pitting edema. Labs revealed troponin I of 3.25ng/mL. EKG showed ventricular-paced rhythm. After diuresis, diagnostic cardiac catheterization was performed and revealed 90% mid-LAD stenosis, 90% distal-LAD stenosis, and 90% proximal LAD stenosis. Cardiothoracic surgery was consulted for CABG however turned down the patient due to high surgical risk. High-risk PCI was considered. TTE revealed LV EF 15% and grade 3 DD. Briefly, Impella use was considered. However, significant RV dysfunction was noted by multiple parameters including RVDd 4.0cm, TR jet area >10cm2, TAPSE 0.6cm, and RV S' 0.07m/s. Therefore, decision was made to use peripheral VA-ECMO. It was established percutaneously using modified Seldinger technique. First, the ACC/AHA type C high-risk mid-LAD lesion was intervened on. Since Whisper MS and Rotowire Floppy could not cross the lesion, five passes of rotational atherectomy were performed. Then, Whisper MS was able to cross and balloon angioplasty as well as deployment of Synergy RX were performed. Second, the distal LAD was intervened on. Balloon angioplasty and deployment of Synergy RX were performed. Third, the proximal LAD was intervened on. Balloon angioplasty and successful apposition of two Synergy RX stents were done. Patient was weaned off ECMO, ventilator, and pressor on POD#1. Cardiac meds were optimized and he was discharged home on POD#3. Discussion
While LV dysfunction is renowned, RV dysfunction is less studied. Some parameters that correlate with dysfunction include RVDd >2.3cm, TR jet area >10cm2, TAPSE <1.7cm, and RV S' <0.1m/s. Worsening of RV dysfunction is a documented complication of LVADs and is associated with high mortality rates. However, through peripheral VA-ECMO, the function of the heart and lungs can be replaced as blood goes from the femoral vein through a pump, then an oxygenator, and back to the femoral artery. As such, both RV and LV dysfunction is absolved. While currently there is no guideline recommendation, this case bolsters the argument for peripheral percutaneous VA-ECMO support for high-risk PCI in the setting of biventricular dysfunction.