Anticipatory use of Venoarterial Extracorporeal Membrane Oxygenation for a High-Risk Interventional Cardiac Procedure

Venoarterial extracorporeal membrane oxygenation (VA ECMO) has become a valuable technique in the critical care of children with congenital heart disease who require mechanical cardiorespiratory support. The use of VA ECMO in cardiac patients has expanded from an extension of intraoperative cardiopulmonary bypass and now includes rescue therapy during cardiopulmonary resuscitation, temporary circulatory support for reversible heart failure, and bridge support preceding heart or heart/lung transplantation. In the majority of clinical applications VA ECMO is used in reaction to impending or ongoing cardiorespiratory failure and not in anticipation of an induced change in clinical status. We describe the anticipatory use of VA ECMO to prepare a patient with complex cyanotic congenital heart disease for a high-risk interventional cardiac catheterization. A 2.5 kg neonate with severe Ebstein's anomaly of the tricuspid valve and recurrent episodes of life-threatening supraventricular tachycardia was electively cannulated for VA ECMO in the cardiac intensive care unit. She underwent successful electrophysiologic mapping and transcatheter radiofrequency ablation of an accessory conduction pathway, resulting in termination of the tachycardia. Following an uncomplicated ECMO course she was decannulated in the cardiac intensive care unit and subsequently discharged home in stable condition. The case illustrates the proactive use of ECMO during a procedure in which severe hemodynamic instability could be predicted. We discuss this concept of ECMO use in the context of accepted indications for ECMO in cardiac patients and encourage an expanded role for its use to prevent cardiorespiratory collapse in planned interventions on compromised patients who are at risk of acute deterioration.