Post-cardiotomy ECMO configurations after mitral valve replacement: a case series and strategy development

Post-Cardiotomy Cardiogenic Shock (PC-CS) after Mitral Valve Replacement (MVR) is a rare but severe complication, which may require ECMO for the acute phase of the illness. These PC-ECMO (Post-Cardiotomy ECMO) are particularly complex cases, as the low flow through the newly replaced valve may cause a very rapid formation of thrombus, blocking the leaflets, that worsens the blood stasis inside the left atrium, extending the thrombosis. To maintain the trans-mitral flow during PC-ECMO, three milestone should be present: the transpulmonary flow should be maintained, the blood reaching the left atrium should be free to cross the mitral prosthesis and the left ventricle should be fully unloaded. The selection of the appropriate PC-ECMO configuration should be guided by the specific functional status of the right ventricle (RV) and left ventricle (LV). When only one ventricle is failing, monoventricular support is preferable. However, when PC-CS involves both ventricles, ex-BiVAD might be a valuable option, but it requires invasiveness on the LV and may be challenging to manage, especially in the early phase of the illness. Conversely, when minimal residual LV function is preserved, the blood flow drained by the venous cannula (V) can be divided into two components, supporting respectively the RV and the systemic circulation. This newly proposed configuration may be referred to as V-PaA ECMO. In this case series, we analyse the physiological implication and the management consideration of three different ECMO configurations: Vpv-A ECMO, V-Pa ECMO (ex-BiVAD) and our newly proposed configuration for biventricular support, V-PaA ECMO. This case series underscores how tailoring PC-ECMO configuration to ventricular physiology can critically influence clinical outcomes, highlighting the need for individualized support strategies after MVR.