Abstract Background Cardiogenic shock from right ventricular (RV) failure secondary to severe pulmonary hypertension carries high mortality. Treatment includes pulmonary vasodilators, volume removal, vasopressor and inotropic support, and consideration of mechanical circulatory support, though these therapies may prove inadequate. In patients with suprasystemic pulmonary arterial (PA) pressures despite maximally tolerated pulmonary vasodilators, procedures such as balloon atrial septostomy (BAS) and reverse Potts shunt (connection between the left main PA and descending aorta) have shown benefit, though experiences in adults and critically ill patients are limited. Case A 33-year-old male with a history of liver failure requiring liver transplantation at age 6 complicated by portopulmonary hypertension on ambrisentan and tadalafil presented with fatigue and dyspnea. He was found to be in cardiogenic shock secondary to RV failure and was cannulated to venoarterial extracorporeal membrane oxygenation (V-A ECMO). Treatment with ambrisentan, inhaled nitric oxide, and IV epoprostenol was initiated, and Sotatercept 0.7mg/kg was given off-label. Attempts to wean V-A ECMO were complicated by hypotension and rising central venous pressure (CVP) requiring escalating vasopressors and inotropes. The patient was deemed ineligible for lung transplantation at multiple institutions. Given inability to wean from ECMO, BAS was performed. Hypotension persisted with subsequent ECMO weaning trials, however CVP did not rise. After multidisciplinary discussion, we opted to create an additional right-to-left shunt with a percutaneous reverse Potts shunt. After shunt creation, the patient was reconfigured from V-A to venovenous (V-V) ECMO to minimize acute hypoxemia and was ultimately decannulated, however became hypoxemic and hypotensive 4 days later and died. Discussion We demonstrate two salvage therapies in a patient with suprasystemic PA pressures and RV failure performed while on V-A ECMO. BAS and reverse Potts shunt create right-to-left shunts to reduce RV preload and afterload and improve RV geometry, function, and LV filling. Management considerations include severe hypoxemia—though reverse Potts shunt, given its location in the descending aorta, spares the brain and upper extremities—and systemic circulation of pulmonary vasodilators which may cause hypotension. In our patient, BAS led to improvement in RV preload, as demonstrated by plateauing CVP with reductions in ECMO flow, though he continued to be intolerant of attempts to wean ECMO. While reverse Potts shunt creation did allow for re-configuration to V-V ECMO and subsequent decannulation, the patient unfortunately died. We illustrate the feasibility of these procedures in a critically ill patient on V-A ECMO, though their utility in such patients remains unclear. This abstract is funded by: None
Fountain et al. (Fri,) studied this question.