Abstract
In patients with cardiogenic shock, the Extra-Corporeal Life Support (ECLS) has been shown to be lives saving. But, in some situations, it proves inadequate for the discharge of the left heart. Several device-based techniques have been proposed to decompress the left side either surgically or percutaneously, each of them with the proper potential risks and complications. One technique, the percutaneous blade and balloon atrioseptostomy that requires transseptal catheter based experience and consists of creating an atrial septal defect (ASD) could be an elegant technique as an “add on” to the classic assistance making together a bridge to partial recovery or to heart transplantation. Herein, we present a case of an adult patient who presented with inaugural resistant cardiac arrest with a thrombotic occlusion of the left anterior descending artery (LAD) who required Extra-Corporeal Life Support, thrombus aspiration, stenting of the culprit lesion, and percutaneous blade and balloon atrioseptostomy to bridge “safely” to the heart transplantation.
1
Introduction
Mechanical life support with Extra-Corporeal Membrane Oxygenation (ECMO) is considered an efficacious circulatory assistance when facing refractory cardiac arrest or cardiogenic shock. It is often used as a bridge to recovery and/or decision making. It serves to restore hemodynamic constants and to limit the myocardial work, which avoid left ventricular dilation, high end-diastolic pressures, increased wall stress, subendocardial ischemia and consequently worsening pulmonary congestion and edema. Sometimes, it promotes myocardial recovery and, sometimes it will be not sufficient to offload the left ventricle especially in patients with large myocardial damage. Percutaneous blade and balloon atrioseptostomy could assume the left ventricular discharge in the right side which is drained via the venous cannula of the ECMO. However, the technique requires transseptal catheter based experience.
2
Case
We report the case of a 49-year-old man, with a history of hypercholesterolemia and no cardiovascular past medical history, who complained of 2-day angina pectoris and presented to the emergency room where he rapidly developed a sudden cardiac arrest. The patient received cardiopulmonary resuscitation that consisted of external cardiac massage, tube ventilation and alternation of vasopressin injections and external electrical chocks. The “no-flow” time was estimated at less than one minute and the “low-flow” at one hour. The heart rhythm was alternation between a sinusal rhythm with anterior ST-segment elevation and recurrent ventricular fibrillation. So, he was immediately assisted by a veno-arterial Extra-Corporeal Membrane Oxygenation (ECMO) via the right femoral access ( Fig. 1 ). His hemodynamics at this stage revealed an invasive systolic blood pressure less than 90 mmHg. The coronary angiography via right radial access demonstrated a thrombotic occlusion (TIMI 0) of the proximal left anterior descending artery (LAD) ( Fig. 2 ). We performed thrombus aspiration with an Export aspiration catheter (Medtronic Corporation, California, USA) ( Fig. 3 ) which generated an anterograde flow of the LAD and stented the underlying stenosis by bare metal stent (PRO Kinetic 3.5 × 18 mm; Biotronik) with a final TIMI 3 flow ( Fig. 4 ). Right heart catheterization through right femoral vena and right auricle angiography showed a stagnation of iodine contrast in the trunk of the pulmonary artery and its branches ( Fig. 5 ) revealing high left ventricle filling pressures and suggesting that the ECMO was insufficient to discharge the left heart. We decided to perform blade and balloon atrioseptostomy (ATS) to manage the severe and refractory acute lung edema. The modified Seldinger technique consists of placing an 8F sheath in the right femoral vein then switching to an 8F Mullins sheath that we advanced into the right atrium. After transseptal puncture with a modified Brockenbrough needle under fluoroscopy, we advanced a 0.035’’ Spring guide-wire into the right upper pulmonary vein. The Mullins sheath was then withdrawn and a 10 mm Marshal balloon was advanced at the level of its mid portion into the septum and inflated with dilute contrast ( Fig. 6 A&B) creating an atrial septal defect (ASD) with left-to-right shunting. Balloon inflation was carried out and the balloon was then pulled back from the left atrium to the right atrium. The left ventricular discharge assumed by the ASD was immediately efficacious on the pulmonary edema and the mean left atrium pressure dropped significantly (from 21 to 12 mmHg) ( Fig. 7 A&B). Indeed, the adequacy of atrioseptostomy was assessed by a better ECMO output ( Fig. 8 ) and the right atrium angiography at this time showed a better blood circulation ( Fig. 9 ). The cardiac ultrasound highlighted a severe myocardial dysfunction (LVEF estimated at 10%). Later, he was transferred to the intensive care unit and treated with UFH in order to obtain an activated clotting time (ACT) of 170 to 200 s. In front of non recuperation of the heart function, the patient received heart transplantation at day three with a favorable evolution and he was discharged on specific medical treatment for heart transplantation and rehabilitation program. He remains events free at six months.
