Left Atrial Veno-Arterial (LAVA) ECMO augmented by IABP successfully offloaded the left ventricle without mechanical aortic valve thrombosis over a 12-day course in a patient with cardiogenic shock.
Case Report (n=1)
LAVA ECMO augmented by IABP may be a feasible strategy to support patients in cardiogenic shock with a mechanical aortic valve and ventricular thrombi, though the risk of cardioembolic events remains a significant concern.
Abstract Introduction The use of Extracorporeal Membrane Oxygenation (ECMO) has revolutionized the management of severe cardiogenic shock refractory to medical management. Typically, Venoarterial (VA) ECMO is augmented by devices used to offload the left ventricle, such as Impella or intra-aortic balloon pumps (IABP), to prevent worsening left heart failure, formation of left ventricular (LV) thrombus, and to permit aortic valve opening. However, in patients with mechanical aortic valves (MAV) or LV thrombus, VA ECMO is relatively contraindicated given high risk of thrombus or embolization. Left Atrial Veno-Arterial (LAVA) ECMO is a promising variation of ECMO that may be useful in overcoming these limitations. Case Presentation A 56 -year-old-male with history of mixed ischemic and nonischemic cardiomyopathy, and bicuspid aortic valve status-post MAV presented for outpatient Left Bundle Branch Pacing Lead revision when an intra-procedure right heart catheterization demonstrated elevated right and left sided filling pressures and a pulmonary artery oxygen saturation of 31.5%, indicating cardiogenic shock. Transthoracic echocardiogram demonstrated severely reduced ejection fraction of 20% with bilateral ventricular thrombi. Despite management with milrinone, furosemide infusion, epinephrine, norepinephrine, and vasopressin, the patient remained in severe cardiogenic shock. IABP was placed and the patient underwent LAVA ECMO cannulation. The patient was weaned off of vasopressor support. Despite medical optimization, the patient failed to have meaningful recovery of cardiac function on ECMO turn-down studies and began evaluation for Left Ventricular Assist Device (LVAD). Discussion The use of LAVA ECMO for management of severe cardiogenic shock refractory to medical management is still evolving. Our case demonstrates the use of LAVA ECMO augmented by IABP in a patient with biventricular heart failure, MAV, and bilateral ventricular thrombi. Successful offloading of the LV without thrombosis of the MAV throughout his 12-day course on LAVA ECMO was achieved. The use of the IABP and milrinone helped further counteract the retrograde flow of ECMO, enabling valvular opening. Current literature regarding the use of LAVA ECMO is still limited concerning prolonged courses in patients with pre-existing MAVs. Our patient unfortunately suffered right hemiplegia on day 12 of ECMO, concerning for cardioembolic stroke, which disqualified him from LVAD candidacy. However, case reports in the literature have shown that LAVA ECMO can be used to support patients with LV thrombus as a bridge to LVAD. Conclusion LAVA ECMO is a potential strategy to support patients in cardiogenic shock with MAV or LV thrombus, though further studies regarding efficacy are warranted. This abstract is funded by: None
Alley et al. (Fri,) conducted a case report in Cardiogenic shock with mechanical aortic valve and ventricular thrombi (n=1). Left Atrial Veno-Arterial (LAVA) ECMO augmented by IABP was evaluated on Successful offloading of the LV without thrombosis of the MAV. Left Atrial Veno-Arterial (LAVA) ECMO augmented by IABP successfully offloaded the left ventricle without mechanical aortic valve thrombosis over a 12-day course in a patient with cardiogenic shock.