Why the study?
Weaning from VA-ECMO presents challenges, and prone positioning is generally avoided during VA-ECMO due to risks such as bleeding and cannula dislodgement.
Radiofrequency catheter ablation for tachycardic AF and prone positioning can be successfully performed as life-saving measures in patients on VA-ECMO for severe cardio-respiratory failure.
May support ablation to wean select VA-ECMO patients; leaves open generalizability and requires prospective trials.
Background: Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is vital for acute cardio-respiratory failure, but challenges persist sometimes in weaning. Prone positioning, beneficial in veno-venous extracorporeal oxygenation (VV-ECMO), is generally avoided in VA-ECMO patients because of the risks such as bleeding from the catheter insertion site and dislodging of the perfusion cannula or tracheal tube. Case summary: A 71-year-old male with paroxysmal atrial fibrillation (AF) presented with dyspnoea. Chest computed tomography (CT) and echocardiogram revealed severe pneumonia and decreased cardiac function [left ventricular ejection fraction (LVEF) 20%]. The patient was diagnosed with heart failure complicated by severe pneumonia. Despite treatment, respiratory and circulatory status deteriorated, necessitating a VA-ECMO. Chest CT showed collapsed lungs, especially on the dorsal side. Thus, prone positioning was initiated under VA-ECMO with attention to potential complications associated with the postural change. Then, his respiratory status was improved dramatically. However, the haemodynamic status could not be probably because of tachycardic AF. Electrical cardioversions failed to maintain sinus rhythm, and heart rate was not adequately controlled. We decided to perform radiofrequency catheter ablation of tachycardic AF under VA-ECMO. Pulmonary vein isolation and conduction block line in the cavo-tricuspid isthmus were made and converted to sinus rhythm, enabling weaning of VA-ECMO. The primary cause of the heart failure was considered to be tachycardia-induced cardiomyopathy, as the LVEF improved to 55%. Discussion: Radiofrequency catheter ablation for AF can be effective even in case of cardio-respiratory failure necessitating VA-ECMO. Furthermore, prone positioning can be performed not only in VV-ECMO but also in VA-ECMO.
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Wakita et al. (2025) studied this question.
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