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Percutaneous left ventricular unloading in cardiogenic shock during venoarterial extracorporeal membrane oxygenation: a radial approach

Open AccessPublished:November 07, 2022DOI:https://doi.org/10.1016/j.cjco.2022.11.003

      Summary

      A 52-year-old man assisted with peripheral venoarterial ECMO developed left ventricular distension, this situation was resolved with the placement of a pigtail catheter in the left ventricle accessed through the left radial artery, guided by transesophageal echocardiography, achieving successful unloading of the ventricle. This new procedure achieves an adequate unload of the left ventricle and can be performed at the patient’s bedside.
      Venoarterial extracorporeal membrane oxygenation (VA ECMO) has expanded beyond refractory cardiogenic shock. A 52-year-old patient with electrical storm was assisted with peripheral VA ECMO. He developed left ventricular distension that resolved with the percutaneous placement of a pigtail catheter in the left ventricle accessed through the left radial artery, guided by transesophageal echocardiography. This article presents a previously undescribed technique that achieved successful unload of the left ventricle and can be performed at the patient’s bedside.

      Keywords

      Introduction

      Cardiogenic shock (CS) is the most severe form of cardiac decompensation and causes end-organ hypoperfusion, multisystem organ failure, and death if a reversible cause is not identified and managed [
      • González-Pacheco H.
      • Manzur-Sandoval D.
      • Gopar-Nieto R.
      • Álvarez-Sangabriel A.
      • Martínez-Sánchez C.
      • Eid-Lidt G.
      • Altamirano-Castillo A.
      • Mendoza-García S.
      • Briseño-Cruz J.L.
      • Azar-Manzur F.
      • Araiza-Garaygordobil D.
      • Sierra-Lara D.
      • Jiménez-Rodríguez G.M.
      • Lazcano-Díaz E.A.
      • Baranda-Tovar F.
      • Valencia-Älvarez J.S.
      • Cutz-Ijchajchal M.A.
      • Penagos-Cordon J.C.
      • Morejon-Barragán P.
      • Arias-Mendoza A.
      Cardiogenic Shock Among Patients with and without Acute Myocardial Infarction in a Latin American Country: A Single-Institution Study.
      ]. Venoarterial extracorporeal membrane oxygenation ( VA ECMO) allows blood to be drained from a central vein and returned to the arterial system providing both respiratory and circulatory support and has been established as a management strategy when CS has been refractory to usual treatment [
      • Tsangaris A.
      • Alexy T.
      • Kalra R.
      • Kosmopoulos M.
      • Elliott A.
      • Bartos J.A.
      • Yannopoulos D.
      Overview of Veno-Arterial Extracorporeal Membrane Oxygenation (VA-ECMO) Support for the Management of Cardiogenic Shock.
      ]. Indications for VA ECMO have been expanded to situations such as support in high-risk interventional procedures and electrical storm. Electrical storm refers to a state of cardiac electrical instability characterized by multiple episodes of ventricular tachycardia (VT) or ventricular fibrillation within a 24-hour period, despite antiarrhythmic drugs or electric therapies [
      • Dyer S.
      • Mogni B.
      • Gottlieb M.
      Electrical storm: A focused review for the emergency physician.
      ]. Currently, peripheral VA ECMO is preferred over central cannulation, due to a lower incidence of complications and the possibility of being performed at the patient's bedside without the need to mobilize the patient to the operating room. [
      • Djordjevic I.
      • Eghbalzadeh K.
      • Sabashnikov A.
      • Deppe A.C.
      • Kuhn E.
      • Merkle J.
      • Weber C.
      • Ivanov B.
      • Ghodsizad A.
      • Rustenbach C.
      • Adler C.
      • Rahmanian P.
      • Mader N.
      • Kuhn-Regnier F.
      • Zeriouh M.
      • Wahlers T.
      Central vs peripheral venoarterial ECMO in postcardiotomy cardiogenic shock.
      ]. During VA ECMO there are complications such as left ventricular distension (LVD); this situation is caused by retrograde flow to the heart, which conditions an increase in the afterload of the left ventricle, a situation that is magnified in those patients with very poor residual ventricular function and in the peripheral cannulation, and if not treated in a timely manner can have a catastrophic outcome. Multiple strategies have been described to achieve adequate discharge of the LV, including the use of IABP, Impella® microaxial flow catheter (Abiomed, Danvers, MA, USA), atrial septostomy, or direct surgical drainage of the LV, left atrium, or pulmonary artery [
      • Donker D.W.
      • Brodie D.
      • Henriques J.P.S.
      • Broomé M.
      Left ventricular unloading during veno-arterial ECMO: a review of percutaneous and surgical unloading interventions.
      ]. In this article, we describe the case of a patient with electrical storm who was supported by peripheral VA ECMO. The patient developed LVD that was resolved percutaneously by the placement of a pigtail catheter in the left ventricle (LV) through the radial artery, guided by transesophageal echocardiography (TEE), achieving a successful unload of the LV. This procedure has not previously been reported in the medical literature.

      Case history

      A 52-year-old man with a medical history of ischemia and dilated cardiomyopathy with a left ventricular ejection fraction of 30% arrived in the emergency department due to multiple episodes of syncope. He carried an implantable cardioverter-defibrillator (ICD) for secondary prevention, and a MitraClipTM (Abbott, Chicago, IL, USA) for secondary severe mitral regurgitation in the context of symptomatic heart failure (in New York Heart Association functional class III) with favorable anatomy for transcatheter edge-to-edge repair two years prior to decompensation. On admission, hypotension and tissue hypoperfusion were noted. A diagnosis of CS was established and management with inotropes (levosimendan) and a vasopressor (norepinephrine) was started. During the clinical evaluation, he developed multiple episodes of unstable VT requiring amiodarone, lidocaine, beta-blockers, and multiple electrical shocks from the ICD. Despite this therapy, the patient continued with episodes of VT, and electrical storm was diagnosed. Our center was consulted and our recommendation to start therapy with peripheral VA ECMO was accepted. With previous placement of an intra-aortic balloon pump (IABP) through the right femoral artery, a double cannulation strategy with a femorofemoral configuration was decided. A 25 French extraction venous cannula (Medtronic plc., Minneapolis, MN, USA) was inserted through the right femoral vein directed toward the mid right atrium, and a 15 French arterial return cannula (Medtronic plc., Minneapolis, MN, USA) was inserted through the left common femoral artery into the mid abdominal aorta. The pulmonary flotation catheter was not placed since we try to avoid stimulation of the right ventricle with the catheter, which could trigger more ventricular arrhythmias in a very irritable myocardium in the context of an electrical storm. Hemodynamic stability was achieved so the patient could be subjected to bilateral stellate ganglion block and VT ablation procedure; automated isochronal late activation mapping with the ablation catheter via a transseptal approach identified deceleration zones in the septum and anterior wall, perfoming radiofrequency ablation successfully in this zones. He remained stable during the procedure. 12 hours after, the patient required higher fraction of oxygen in the gas mixer and congestion of the vascular bed in the chest x-ray (Figure 1) and developed LVD (despite management with inotropes and an IABP) with spontaneous echo contrast (Figure 2A), absence of opening of the aortic valve (Figure 2B, Video 1), and pulmonary edema. At that time his systemic blood pressure was 80/30 mmHg and the blood flow of the ECMO had to be decreased to 2.3 liters per minute to limit afterload and LVD. Impella® was not available at that moment in our center. Because the patient could not be transferred to the catheterization laboratory because of extreme hypotension, a 6 French pigtail catheter (Cordis US corp., Miami Lakes, FL, USA) was introduced through the left radial artery with a 6 French sheath introducer (Figure 2C). Its passage through the aorta toward the LV cavity was guided in real time with TEE (Figure 2D). The transgastric long axis view in the transesophageal echocardiogram allowed us the visualization of the subvalvular mitral valve apparatus, including the chordae tendineae, so we were able to ensure the placement of the catheter in the mid-ventricular region without injuring these structures. The correct position of the tip was confirmed with a portable chest X-ray (Figure 2E). Then, the pigtail catheter was connected to the extraction cannula (Figure 2F). TEE showed resolution of LVD as well as the spontaneous echo contrast and opening of the aortic valve (Figure 2G, Video 2). In addition, the left ventricular end-diastolic pressure was measured, giving a value of 7 mmHg (Figure 2H). An increase in systemic blood pressure to 100/70 mmHg was documented and it was possible to increase the blood flow of the ECMO to 3 liters per minute, without evidence of hemolysis. We anticoagulate the patient with unfractioned heparin and a partial thromboplastin time target of 70–80 seconds while using the pigtail. We only use it for 48 hours before removing it without any evidence of catheter thrombosis, limb ischemia or neurologic issues. After 5 days of mechanical circulatory support, the patient could be weaned off the VA ECMO.
      Figure thumbnail gr1
      Fig. 1Chest X-ray showing congestion of the vascular bed.
      Figure thumbnail gr2
      Fig. 2Panel A: TEE 4-chamber view. Dilated LV with spontaneous echo contrast (white arrow). Panel B: absence of opening of the aortic valve and spontaneous echo contrast in the aortic root (white arrow). Panel C: Through a 6 French sheath introducer in the left radial artery (black arrow) a 6 French pigtail catheter is introduced to the left ventricular cavity (white arrow). Panel D: Real-time TEE guidance showing the catheter passage through the aortic valve (white arrow) into the left ventricular cavity (3-chamber view). Panel E: Chest X-ray showing the tip of the catheter at the left ventricular cavity (white arrow). Panel F: The pigtail catheter is connected directly to the extraction cannula (black arrow). Panel G: Real-time TTE showing the opening of the aortic valve (white arrow) after the drainage is initiated (3-chamber view). Panel H: Left ventricular end-diastolic pressure of 7 mmHg is registered., TEE: transesophageal echocardiography, LV: left ventricle

      Discussion

      One of the most feared complications that occurs during VA ECMO is LVD. VA ECMO generates increased afterload and the LV may not be able to eject blood sufficiently. The aortic valve remains closed and LVD may result, giving rise to elevated pulmonary artery pressures, pulmonary edema, thrombosis, and arrhythmias and hindered LV recovery [
      • Rupprecht L.
      • Flörchinger B.
      • Schopka S.
      • Schmid C.
      • Philipp A.
      • Lunz D.
      • Müller T.
      • Camboni D.
      Cardiac decompression on extracorporeal life support: a review and discussion of the literature.
      ]. Direct percutaneous drainage of the LV via the interatrial septum or transaortically has been described, the latter being via an axillary or femoral artery approach [
      • Barbone A.
      • Malvindi P.G.
      • Ferrara P.
      • Tarelli G.
      Left ventricle unloading by percutaneous pigtail during extracorporeal membrane oxygenation.
      ]. It is important to mention that frequently the two common femoral arteries are occupied (by the IABP and the arterial cannula of the ECMO), and the axillary access can be difficult percutaneously, often requiring surgical assistance.

      Conclusion

      In this case, we present for the first time a proposal for direct unloading of the LV by the placement of an intraventricular catheter through a radial route. This method is easily accessible and has the advantage that it can be performed at the patient’s bedside with echocardiographic guidance, achieving an adequate discharge of the LV both by image and hemodynamic measurements. This strategy can be applied especially in centers with limited resources or where the usual cannulation devices for LV unloading are not available or scarce.

      Novel teaching points

      • One of the complications of peripheral VA ECMO is left ventricular distension
      • Left ventricular distension can cause pulmonary edema, thrombosis, and refractory arrhythmias.
      • Drainage of the left ventricle with a pigtail catheter accessed through the radial artery is technically feasible.

      Supplementary material

      References

        • González-Pacheco H.
        • Manzur-Sandoval D.
        • Gopar-Nieto R.
        • Álvarez-Sangabriel A.
        • Martínez-Sánchez C.
        • Eid-Lidt G.
        • Altamirano-Castillo A.
        • Mendoza-García S.
        • Briseño-Cruz J.L.
        • Azar-Manzur F.
        • Araiza-Garaygordobil D.
        • Sierra-Lara D.
        • Jiménez-Rodríguez G.M.
        • Lazcano-Díaz E.A.
        • Baranda-Tovar F.
        • Valencia-Älvarez J.S.
        • Cutz-Ijchajchal M.A.
        • Penagos-Cordon J.C.
        • Morejon-Barragán P.
        • Arias-Mendoza A.
        Cardiogenic Shock Among Patients with and without Acute Myocardial Infarction in a Latin American Country: A Single-Institution Study.
        Glob Heart. 2021 Nov 30; 16: 78https://doi.org/10.5334/gh.988
        • Tsangaris A.
        • Alexy T.
        • Kalra R.
        • Kosmopoulos M.
        • Elliott A.
        • Bartos J.A.
        • Yannopoulos D.
        Overview of Veno-Arterial Extracorporeal Membrane Oxygenation (VA-ECMO) Support for the Management of Cardiogenic Shock.
        Front Cardiovasc Med. 2021 Jul 7; 8686558https://doi.org/10.3389/fcvm.2021.686558
        • Dyer S.
        • Mogni B.
        • Gottlieb M.
        Electrical storm: A focused review for the emergency physician.
        Am J Emerg Med. 2020 Jul; 38: 1481-1487https://doi.org/10.1016/j.ajem.2020.04.017
        • Djordjevic I.
        • Eghbalzadeh K.
        • Sabashnikov A.
        • Deppe A.C.
        • Kuhn E.
        • Merkle J.
        • Weber C.
        • Ivanov B.
        • Ghodsizad A.
        • Rustenbach C.
        • Adler C.
        • Rahmanian P.
        • Mader N.
        • Kuhn-Regnier F.
        • Zeriouh M.
        • Wahlers T.
        Central vs peripheral venoarterial ECMO in postcardiotomy cardiogenic shock.
        J Card Surg. 2020 May; 35: 1037-1042https://doi.org/10.1111/jocs.14526
        • Donker D.W.
        • Brodie D.
        • Henriques J.P.S.
        • Broomé M.
        Left ventricular unloading during veno-arterial ECMO: a review of percutaneous and surgical unloading interventions.
        Perfusion. 2019 Mar; 34: 98-105https://doi.org/10.1177/0267659118794112
        • Rupprecht L.
        • Flörchinger B.
        • Schopka S.
        • Schmid C.
        • Philipp A.
        • Lunz D.
        • Müller T.
        • Camboni D.
        Cardiac decompression on extracorporeal life support: a review and discussion of the literature.
        ASAIO J. 2013 Nov-Dec; 59: 547-553https://doi.org/10.1097/MAT.0b013e3182a4b2f6
        • Barbone A.
        • Malvindi P.G.
        • Ferrara P.
        • Tarelli G.
        Left ventricle unloading by percutaneous pigtail during extracorporeal membrane oxygenation.
        Interact Cardiovasc Thorac Surg. 2011 Sep; 13: 293-295https://doi.org/10.1510/icvts.2011.269795