Severe Aortic Insufficiency-Induced Cardiogenic Shock Treated with Left Atrial VA-ECMO and Emergent Valve-in-Valve TAVR

Figures

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  Figure 1. Anteroposterior radiographs of the chest revealing (A) mild bilateral pulmonary oedema on admission and (B) worsening bilateral pulmonary infiltrates and vascular congestion upon endotracheal intubation and transfer to the intensive care unit. One should note the absence of sternotomy suture wires—this is explained by the fact that the patient's surgical aortic valve replacement had been performed via a minimally invasive technique with right anterior minithoracotomy with closure utilizing titanium suture fasteners.

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  Figure 2. Successful percutaneous cannulation and initiation of left atrial venoarterial extracorporeal membrane oxygenation with distal perfusion catheter to the lower extremity: (A) 21‐French trans‐septal left atrial drainage cannula via right femoral venous access; (B) large 25‐French systemic venous drainage cannula via left femoral venous access; and (C) 17‐French systemic arterial return cannula. Flows from both venous cannulas merge via a Y‐connector and return blood to the extracorporeal membrane oxygenation oxygenator via a single tubing.

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  Figure 3. Timeline of diagnosis and major interventions from time of inpatient rapid response alert to successful extubation. ACS, acute coronary syndrome; AI, aortic insufficiency; AVR, aortic valve replacement; CI, cardiac index; CRRT, continuous renal replacement therapy; CTA, computed tomography angiography; ECMO, extracorporeal membranous oxygenation; EF, ejection fraction; ICU, intensive care unit; LAD, left anterior descending artery; LAVA‐ECMO, left atrial venoarterial extracorporeal membranous oxygenation; LHC, left heart catheterization; NSTEMI, non‐ST‐elevation myocardial infarction; PCI, percutaneous coronary intervention; RHC, right heart catheterization; SvO2, systemic venous oxygen saturation; TEE, transoesophageal echocardiography; TTE, transthoracic echocardiography; ViV‐TAVR, valve‐in‐valve transaortic valve replacement.