VA-ECMO as a Bridge to Transplant Following Apical Wall Rupture
Presenter
Hannah Every, MD, Mount Sinai Hospital, New York, NY
Hannah Every, MD1, Greg W Serrao, MD, FSCAI2, Ashish Correa, MD3, Sunny Goel, MD4, Umesh Gidwani, MD, FSCAI2, Sean Pinney, MD3 and Anelechi Anyanwu, MD5, (1)Mount Sinai Hospital, New York, NY, (2)Icahn School of Medicine at Mount Sinai, New York, NY, (3)Icahn School of Medicine at Mount Sinai Morningside, New york, NY, (4)Icahn School of Medicine at Mount Sinai, Albertson, NY, (5)Icahn School of Medicine at Mount Sinai, New York City, NY
Title
VA-ECMO as a Bridge to Transplant Following Apical Wall Rupture
Introduction
Cardiac rupture is a feared complication of ST-segment elevation myocardial infarction (STEMI) and often results in cardiac tamponade and death unless surgically corrected. The role of veno-arterial extracorporeal membrane oxygenation (VA-ECMO) in cases of left ventricular (LV) rupture has historically been limited to the preoperative setting before definitive surgical intervention. We present a case of late presenting STEMI with apical wall rupture and hemopericardium who was stabilized on ECMO prior to orthotopic heart transplantation (OHT).
Clinical Case
A 50-year-old male without significant past medical history presented to an outside hospital with one week of chest pain. Initial ECG demonstrated anterior STEMI. He underwent angiography revealing total occlusion of the mid-LAD and high-grade stenosis of the proximal RCA. A small ventricular septal defect (VSD), LV mural thrombus, and large apical aneurysm were seen. Due to concern for cardiogenic shock, inotropes were initiated and an intra-aortic balloon pump (IABP) was placed prior to patient transfer for possible surgical intervention. Upon transfer, echocardiogram revealed severely reduced ejection fraction with extensive mid-septal and apical transmural infarction with minimal tissue viability, limiting the utility of VSD repair or revascularization. He was stabilized on medical therapy while advanced therapies workup was initiated. On the 17th day of admission, the patient became unresponsive and pulseless. CPR was initiated and peripheral extracorporeal resuscitation (ECPR) was required to achieve return of circulation. The venous cannula was placed such that it terminated in the superior vena cava (SVC). He was transferred to the ICU where an echocardiogram revealed cardiac tamponade with hemopericardium containing mobile thrombi and rupture of LV apical pseudoaneurysm. His ICU course was complicated by a right parietal embolic stroke. He maintained all end organ function and was extubated and neurologically intact, other than mild left arm weakness. Given the degree of myocardial disruption and multiple thrombi, surgical repair was deemed to have a low likelihood of success with a high probability of stroke. The decision was made to emergently list for OHT. The patient was maintained on ECMO without the use of anticoagulation for four days before undergoing successful OHT. The patient was discharged two months later with near total resolution of neurologic deficits.
Discussion
This case demonstrates the successful use of VA-ECMO in a patient with contained hemopericardium following LV rupture as a bridge to transplant. Rupture with pericardial tamponade is thought to have a low likelihood of resuscitation with ECMO because of perceived difficulty maintaining systemic and cerebral perfusion pressures. This is thought to be due to the inability to optimize venous drainage as a result of high pericardial pressures, which can be exacerbated by retrograde flow from the return cannula. This case demonstrates that a combination of high venous inflow position, limited anticoagulation, and optimization prior to definitive surgical intervention can yield a successful outcome.